Every finding on record at Lane Nursing & Ventilator Care

Based on record review and interview, the facility failed to complete comprehensive assessments for 2 (#21 and #27) of 4 sampled residents reviewed for assessments. The DON identified 37 residents resided in the facility. Findings: 1. A review of the medical record for Resident #21 showed quarterly assessments had been completed on 08/19/25, 11/17/25, and 02/17/26. There was no documentation to show an annual assessment had been completed in 05/2026.2. A review of the medical record for Resident #27 showed quarterly assessments had been completed on 08/11/25, 11/10/25, and 02/09/26. There was no documentation to show an annual assessment had been completed in 05/2026.On 07/17/26 at 9:25 a.m., the MDS (minimum data set) coordinator stated they missed the comprehensive annual assessment that should have been completed in 05/2026 for Residents #21 and #27.

Based on record review and interview, the facility failed to develop a comprehensive care plan for classifications of prescribed medications which required monitoring for 1 (#2) of 5 sampled residents reviewed for unnecessary medications. The ADON identified 37 residents received medications in the facility. Findings: A physician's order for Resident #2, dated 06/10/24, showed to administer Eliquis (anticoagulant) 5 mg twice daily. A physician's order for Resident #2, dated 10/03/25, showed to administer clobazam (anticonvulsant) 5 mg twice daily. A physician's order for Resident #2, dated 10/13/25, showed to administer buspirone (antianxiety) 15 mg twice daily. A physician's order for Resident #2, dated 02/04/26, showed to administer mirtazapine (antidepressant) 15 mg every evening. A care plan for Resident #2, dated 04/06/26, did not show interventions to address the resident's prescribed anticoagulant, antidepressant, anticonvulsant, or antianxiety medications. On 07/17/26 at 11:43 a.m., the care plan coordinator stated the anticoagulant, antidepressant, anxiolytic, and anticonvulsant medication should have been care planned.

Based on observation and interview, the facility failed to: a. sanitize reusable medical equipment between resident use for 1 (#12) of 28 sampled residents observed for medication administration; and b. maintain infection control during incontinent care for 1 (#2) of 1 sampled resident observed for incontinent care. The DON identified 37 residents resided in the facility. The ADON identified 27 residents incontinent of urine. Findings: On 07/17/26 at 8:37 a.m., ACMA #1 was observed to obtain a resident's blood pressure with a wrist cuff before administering medication. ACMA #1 was observed to obtain Resident #12's blood pressure with the same blood pressure cuff without sanitizing the cuff in between the residents. On 07/17/26 at 8:45a.m., ACMA #1 stated the blood pressure cuff should have been sanitized between residents, but they cannot sanitize the material the blood pressure cuff was made of. On 07/17/26 at 3:30 p.m., the ADON stated they needed to get blood pressure cuffs that could be sanitized. 2. On 07/14/26 at 11:45 a.m., an isolation gown was observed hanging from a hook on the wall of Resident #2's room. On 07/17/26 at 10:35 a.m., CNA #1 and CNA #2 were observed to provide incontinent care to Resident #2. CNA #2 was not observed to have changed gloves after cleaning the resident of urine incontinence. CNA #1 was observed to have touched the clean pad, new brief, positioning pillows, pillowcase on pillow under the resident's head, pulled down the resident's shirt, and touched the resident's skin while wearing the same pair of gloves. On 07/14/26 at 11:35 a.m., Resident #2 stated the staff had used the isolation gown hanging on the wall more than once. On 07/17/26 at 11:57 a.m., CNA #1 stated they used personal protective equipment, gloves, and gowns when performing incontinent care. CNA #1 stated they wore a face shield when appropriate. CNA #1 stated they did not reuse the isolation gowns and thought the isolation gowns hanging were from the night shift. CNA #1 stated when the resident was incontinent of just urine, they would complete the incontinent care before changing their gloves. CNA #1 stated they should have changed their gloves after wiping the urine from the resident's skin and before touching anything that was clean. On 07/17/26 at 2:13 p.m., the ADON stated staff should change gloves after providing incontinent care and before applying/touching anything that was clean.

Based on observation, record review, and interview, the facility failed to update the care plan for the use of a urinary catheter for 1 (#5) of 12 sampled residents reviewed for urinary catheters. The assistant director of nursing identified five residents with urinary catheters in the facility. Findings: On 07/15/26 at 9:22 a.m., Resident #5 was observed to have a urinary catheter. On 07/17/26 at 1:10 p.m., LPN #1 was observed providing catheter care to Resident #5 A care plan for Resident #5, dated 09/01/25, showed urinary catheter care and maintenance interventions had been discontinued. A physician order for Resident #5, dated 07/17/26, showed urinary catheter care twice daily and as needed. On 07/17/26 at 1:59 p.m., the care plan coordinator stated someone had discontinued the care plan for the urinary catheter, and they needed to update the care plan to reflect the current interventions for the urinary catheter.

Based on observation and interview, the facility failed to: a. maintain a clean ice machine, andb. serve a meal in a sanitary manner for 1 of 1 meal service observation. The ADON identified 28 residents received meals served from the kitchen. Findings: On 07/15/26 at 11:55 a.m., [NAME] #1 was observed with a beard guard/hair net on. The beard guard/hair net was positioned around the cook's chin and was not observed to cover the entire beard or their mustache. On 07/15/26 at 11:56 a.m., [NAME] #1 and [NAME] #2 were observed to use gloved hands to serve food from the steam table, touching handles of utensils, their clothing, face, steam table surface areas, kitchen food preparation areas, and food trays. [NAME] #2 was observed to place their thumbs over the edge and onto the top of the residents' plates where food was plated. [NAME] #1 and [NAME] #2 were observed to use the same gloved hands to crush tortilla chips onto the residents' plates while plating taco salad. On 07/15/26 at 12:02 p.m., DA #1 was observed to use gloved hands to serve resident meals to the residents at their dining tables. DA #1 was observed to use gloved hands at the dining table to open a resident's burrito and add salsa and sour cream before rolling the burrito back up for the resident. On 07/17/26 at 2:49 p.m., [NAME] #1 stated the beard guard/hair net was too small to cover their beard. [NAME] #1 stated they used gloves and washed their hands to minimize the risk of transferring infection. 2. On 07/17/26 at 2:52 p.m., the ice machine was observed with [NAME] #1. The ice machine had red, grey, and black patches of substance which had a furry looking texture. On 07/17/26 at 2:53 p.m., [NAME] #1 stated the ice machine was dirty with red, black, and grey fuzzy looking growth. On 07/17/26 at 3:00 p.m., the ADON was informed of the dining room/kitchen observations. The ADON stated they should not touch the residents' food with gloved hands.

Based on observation, record review, and interview, the facility failed to ensure: a. residents with indwelling medical devices were placed on EBP for 17 (#4, 9, 10, 11, 13, 15, 16, 17, 18, 19, 20, 21, 26, 28, 29, 30, and #31) of 25 sampled resident reviewed for EBP; and b. required PPE was worn by staff while providing tracheostomy care for 3 (#10, 11, and #12) of 3 sampled residents reviewed for tracheostomy care. The ADON identified 21 residents that had tracheostomy tubes in place at the facility and 19 residents that had PEG tubes in place at the facility. Findings: A. On 03/05/25 at 2:32 p.m., a tour of the facility was conducted and 10 rooms (#23, 28, 29, 30, 31, 32, 33, 40, 41, and #43) that were occupied by residents with either a tracheostomy, and PEG tube or both. None of the 10 rooms had a sign or other indicator that the occupants of the room were on EPB. On 03/06/25 at 10:24 a.m., a tour of the facility was conducted. Ten resident rooms (#23, 28, 29, 30, 31, 32, 33, 40, 41, and #43) previously identified as those whose occupants had indwelling medical devices, but and continued to lack EBP indicators. On 03/11/25 at 1:45 p.m., a tour of the facility was conducted. The same 10 rooms (#23, 28, 29, 30, 31, 32, 33, 40, 41, and #43) were occupied by residents with indwelling medical devices and the rooms did not have any type of indicator the residents were on EBP. A document titled Escalation to LTC [Long Term Care] regarding Candida auris at Lane Nursing and Ventilator Care, showed on 05/30/24 the Oklahoma State Department of Health's Healthcare-associated Infections and Antimicrobial Resistance (HAI/AR) program had contacted the facility's DON/IP and conducted a telephone infection control assessment which identified the facility's lack of use of EBP. The document further showed the HAI/AR team conducted an onsite visit to the facility on [DATE] and the team found EBP had not been initiated. An undated document titled Lane Nursing and Vent Infection Control Program Overview, read in part, The goals of the infection control program are to: a. Decrease the risk of infection to residents and personnel b. Monitor for occurrence of infection and implement appropriate control measures c. Identify and correct problems relating to infection control practices d. Insure compliance with state and federal regulations relating to infection control. An undated resident room roster showed which residents had tracheostomies and the room where they resided. The roster showed the ADON wrote on the document Res [ the letter c with a slash above it to stand for the word with] trach[tracheostomy], to identify purpose of the document. The roster identified the following room assignments: a. room [ROOM NUMBER] was occupied by Res #9 and Res #28; b. room [ROOM NUMBER] was occupied by Res #29 and Res #30; c. room [ROOM NUMBER] was occupied by Res #10 and Res #11; d. room [ROOM NUMBER] was occupied by Res #16 and Res #17; e. room [ROOM NUMBER] was occupied by Res #18 and Res #19; f. room [ROOM NUMBER] was occupied by Res #20 and Res #21; g. room [ROOM NUMBER] was occupied by Res #25; h. room [ROOM NUMBER] was occupied by Res #26; and i. room [ROOM NUMBER] was occupied by Res #13 and Res #14. An undated resident room roster showed which residents had PEG tubes and the room where they resided. The roster showed the ADON wrote on the document, Res [ the letter c with a slash above it to stand for the word with] PEG, to identify the purpose of the document. The roster identified the following room assignments: a. room [ROOM NUMBER] was occupied by Res #31; b. room [ROOM NUMBER] was occupied by Res #4; c. room [ROOM NUMBER] was occupied by Res #10 and Res #11; d. room [ROOM NUMBER] was occupied by Res #12; e. room [ROOM NUMBER] was occupied by Res #16 and Res #17; f. room [ROOM NUMBER] was occupied by Res #18 and Res #19; g. room [ROOM NUMBER] was occupied by Res #20 and Res #21; h. room [ROOM NUMBER] was occupied by Res #25; and i. room [ROOM NUMBER] was occupied by Res #26. On 03/11/25 at 2:05 p.m., LPN #1 stated residents on EBP all had a sign on their door and a container of the required PPE outside their door. LPN #1 stated residents were placed on EBP because they had certain types of infections. LPN #1 stated they were unaware of any other reason a person would be on EBP. They stated they had not used EBP PPE for any resident other that those with the EBP signs. On 03/11/25 at 2:08 p.m., LPN #2 stated they can identify residents on EBP by the sign and PPE outside their door. LPN #2 stated they had used standard precautions for the residents without the EBP signs. On 03/11/25 at 2:10 p.m., CMA #1 stated they had used the EBP required PPE for residents with the EBP signs and standard precautions for the other residents. On 03/11/25 at 2:12 p.m., CMA #2 stated they had used EBP PPE only for the residents with the EBP signs. CMA #2 stated they use standard precautions for the other residents. On 03/11/25 at 2:15 p.m., CNA #1 stated residents with certain types of infections were placed on EPB and that required extra PPE. CNA #1 stated they had used standard precautions on the other residents. CNA #1 stated Res #10, 11, and #12 were not on EBP so they had been using standard precautions with them. B. 1. On 03/12/25 at 7:45 a.m., RRT #1 was observed providing tracheostomy care to Res #10. Res #10's assigned room did not have an EBP sign or container of PPE outside of the door. RRT #1 was observed providing the care which included suctioning the resident and replacing the inner cannula. They performed the care with only the use of treatment gloves and cleaning of their hands as infection control measures. Res #10 had diagnoses which included encounter for attention to tracheostomy and encounter for attention to gastrostomy. A document titled Doctor's Orders V2 3 Hole, dated March 2025, showed Res #10 was to receive PEG tube care daily and tracheostomy care twice daily. A document titled Routine/PRN Treatments, dated March 2025, showed Res #10 had received PEG tube care daily on 03/01/25 and 03/11/25. A document titled Respiratory Report, dated March 2025, showed Res #10 had received tracheostomy care on 03/01/25 and 03/11/25. 2. On 03/12/25 at 7:50 a.m., RRT #1 was observed providing tracheostomy care to Res #11. The resident's assigned room did not have an EBP sign or a container of PPE outside of the door. During the care RRT #1 suctioned the resident and replaced the inner cannula. The only infection prevention methods used during the care was the use of treatment gloves and hand washing. Res #11 had diagnoses which included encounter for attention to tracheostomy and encounter for attention to gastrostomy. A document titled Doctor's Orders V2 3 Hole, dated March 2025, showed Res #11 was to receive PEG tube care daily, and tracheostomy care twice daily. A document titled Routine/PRN Treatments, dated March 2025, showed Res #11 had received PEG tube care daily on 03/01/25 through 03/11/25. A document titled Respiratory Report, dated March 2025, showed Res #11 had received tracheostomy care on 03/01/25 through 03/11/25. 3. Res. #12 had diagnoses which included encounter for attention to tracheostomy and encounter for attention to gastrostomy. A document titled Doctor's Orders V2 3 Hole, dated March 2025, showed Res #12 was to receive PEG tube care daily, and tracheostomy care twice daily. A document titled Routine/PRN Treatments, dated March 2025, showed Res #12 had received PEG tube care daily and tracheostomy care twice daily on 03/01/25 through 03/11/25. On 03/12/25 at 7:56 a.m., RRT #1 was observed providing tracheostomy care to Res #12. The resident's assigned room did not have an EBP sign or a container of PPE outside the door. RRT #1 was observed providing the care which included replacing the resident's inner cannula and suctioning. RRT #1 was observed providing the care using only treatment gloves and hand washing as their only protective measures. On 03/12/25 at 8:00 a.m., RRT #1 stated they provide tracheostomy care to residents using gloves and hand washing unless they are on EBP and then they add the use of masks and gowns. RRT #1 stated they had never used gowns and masks unless a resident was on EBP or another type of precaution that would require it. RRT #1 stated they know if a resident was on EBP because of the signs. RRT #1 stated Res #10, 11, and #12 did not have the EBP signs because they did not have the infections that would require them. RRT #1 stated they did know any other reason a person would be put on EBP. On 03/12/25 at 12:45 p.m., the ADON stated Res #10, 11, and #12 had required PEG tube and tracheostomy care at the facility since their admission. On 03/12/25 at 1:15 p.m., the ADON stated they were the infection preventionist at the facility. They stated they understood that EBP was used for residents with certain types of infections and that the use of EBP for residents with PEG tubes and tracheostomies was recommended but not required. They stated they had not used EBP for residents just because they had thracheostomy tubes or PEG tubes. They stated they thought EBP use for those residents was not mandatory.

Based on observation, record review, and interview, the facility failed to ensure power strips were not used to supply power to medical devices for 3 (#17, 21, and #24) of 17 sampled residents reviewed for tracheostomy care. The ADON identified 23 residents had tracheotomies at the facility. Findings: 1. On 03/25/25 at 12:25 p.m., Res #17 was observed in bed. Their flowby machine and suctioning machine were observed to be plugged into a gray power strip. Res #17's admission record, dated 09/22/22, showed the resident had diagnosis which included encounter for attention to tracheostomy. On 03/25/25 at 12:26 p.m., the MDS coordinator stated Res #17's flowby and suctioning machine were plugged into the gray power strip. 2. On 03/25/25 at 12:29 p.m., Res #21 was observed in bed. Their nebulizer and suctioning machine were plugged into a gray power strip. Res #21's admission record, dated 08/19/22, showed the resident had diagnosis which included encounter for attention to tracheostomy. On 03/25/25 at 12:31 p.m., the MDS coordinator stated Res #21's nebulizer and suctioning machine were plugged into a gray power strip. 3. On 03/25/25 at 12:30 p.m., Res #24 was observed in bed. Their ventilator was observed operating and plugged into a black power strip. Res #24's admission record, dated 01/31/25, showed the resident had diagnoses which included muscular dystrophy and acute respiratory failure. On 03/25/25 at 12:31 p.m., the MDS coordinator stated Res #24's ventilator was plugged into a black power strip. On 03/27/25 at 3:20 p.m., the DON stated they did not have a policy for the use of power chords. They stated the medical devices should have been plugged in directly to the outlets on the wall.

Based on record review and interview, the facility failed to ensure RN coverage for eight consecutive hours, seven days per week. The ADON identified 43 residents resided in the facility. Findings: A PBJ Staffing Report, dated 04/01/24 through 06/30/24, did not document any RN hours for 04/06/24, 04/07/24, 04/20/24, 04/27/24, 04/28/24, 05/05/24, 05/11/24, 05/12/24, 05/18/24, 05/19/24, 05/26/24, 05/27/24, 06/01/24, 06/02/24, 06/08/24, 06/09/24, and 06/16/24. On 10/22/24 at 8:25 a.m., the interim administrator stated they did not have documentation of RN coverage for those dates.

Based on observation and interview, the facility failed to ensure residents' dignity was maintained when they received care for two (#8 and #38) of three sampled resident reviewed for dignity. The ADON identified there were 43 residents who resided in the facility. Findings: 1. Resident #8 had diagnoses which included anoxic brain damage and chronic respiratory failure. On 10/21/24 at 11:44 a.m., RT #1 was observed providing vent care to Resident #8. During the care RT #1 did not close the door, the curtain blocking the doorway, or the curtain between Resident #8 and their roommate Resident #29. After completion of the care RT #1 stated they always left the door open so they could hear if someone called them. They stated they left the curtain open because the resident's roommate liked to have it opened. On 10/21/24 at 1:25 p.m., Resident #29 stated it would not bother them at all if the curtain was closed while Resident #8 received care. 2. Resident #38 had diagnoses which included encephalopathy and pressure ulcer of the sacral region, stage four. On 10/22/24 at 8:03 a.m, LPN #2 was observed providing peri-care to Resident #38. During the care the curtain between Resident #38 and their roommate was left open. On 10/22/24 at 8:20 a.m., LPN #2 was asked if anything could have been done different during the care. They stated they should have closed the curtain to maintain Resident #38's dignity. On 10/22/24 at 11:24 a.m., the ADON stated the resident's dignity should always be considered during any type of care. RT #1 and LPN #2 should have closed the doors and curtains.

Based on record review and interview, the facility failed to ensure quarterly MDS assessments were completed for three (#13, 37, and #39) of fourteen sampled residents reviewed for MDS assessments. The ADON stated 43 residents resided at the facility. Findings: A facility policy MDS Completion and Submission Timeframe's, dated October 2010, read in part, Our facility will conduct and submit resident assessments in accordance with current federal and state submission time frame. A review of resident records for quarterly MDS assessments found that Residents #13, 37, and #39 assessments were past the creation and submission dates. On 10/22/24 at 12:48 p.m., MDS Coordinator #1 stated they had reviewed the records and found the quarterly MDS assessments for the three residents were indeed late. They stated the quarterly assessments had not been started and that was their mistake. On 10/22/23 at 1:53 p.m., the ADON stated all the MDS assessments needed to be done timely and the assessments not having been started was a violation of their policy.

Based on observation, record reviewed, and interview, the facility failed to ensure a resident's use of devices for contractures to prevent worsening was care planned for one (#8) of two sampled residents reviewed for positioning. The ADON stated 43 residents resided at the facilty. Findings: Resident #8 had diagnoses which included contracture and unspecified hand and coma. A review of Resident #8's care plan, dated 08/14/24, found no documentation regarding the presence or care for hand contractures. On 10/20/24 at 10:46 a.m., Resident #8's hands were observed to be contracted. No devices to protect the hands or prevent further worsening of contractures were observed. On 10/22/24 at 8:21 a.m., Resident #8 was observed to have rolled cloth inside both contracted hands. On 10/22/24 at 1:21 p.m., CNA #6 stated they do keep rolled cloths or carrots (term for a device to place in a persons contacted hand) in the hands of those with contractures. They stated they have to be removed periodically to prevent pain and prevent damage from moisture. They stated they did not know if the use of the devices were care planned. On 10/22/24 at 1:30 p.m., CMA #1 stated they do use carrots or rolled cloth to put in contracted hands. They stated they had taken out some over the weekend before the survey. They were not sure they were in the care plan and just did it from experience. On 10/22/24 at 2:05 p.m., the ADON stated they had reviewed the resident's care plan and physician orders and had found no documentation of the use of carrots for the contractures. They stated the staff did put them in to prevent progression and injury. They stated they are put in and taken out at intervals. They stated the care of the contracture should have been care planned.

Based on observation and interview, the facility failed to: a. ensure a LPN washed or disinfected their hands while providing wound care to one (#38) of two sampled residents reviewed for wound care; and b. have a waterborne pathogen plan. The ADON identified 43 residents resided in the facility. Findings: Resident #38 had diagnoses which included, pressure ulcer of the sacrum, stage four. On 10/22/24 at 8:03 a.m., LPN #2 was observed providing wound care to Resident #38. During wound care LPN #2 was observed repeatedly changing gloves after each step of the process, but failed to wash or disinfect their hands between dirty and clean steps. This resulted in LPN #2 potentially contaminating each set of new gloves after removing the old gloves that came into contact with the resident's body, the wound, and each contaminated wound care product they had used. On 10/22/24 at 9:17 a.m., LPN #2 was asked how often they had washed or disinfected their hands during Resident #38's wound care. They stated, Not one time. On 10/22/24 at 11:53 a.m., the ADON stated during any type of care the staff member must remove their gloves, clean their hands, and replace their gloves before proceeding to the next step. They stated stated LPN #2 had not provided care properly and risked spreading infections. They stated that was not good practice. On 10/23/24 at 9:51 a.m., the administrator stated after searching records they did not believe there was a working waterborne pathogen plan in place. They stated they would contact the maintaince supervisor to be sure. On 10/23/24 at 10:13 a.m., the ADON stated there was no waterborne pathogen plan in place.

Based on interview and record review, the facility failed to ensure weekly skin assessments were completed for one (#7) of five sampled residents reviewed for unnecessary medications. The ADON identified 43 residents resided in the facility. Findings: A Pressure Ulcer Risk Assessment policy, revised 10/10, read in part .Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated .Nurses will conduct skin assessments at least weekly to identify changes . Resident #7 had diagnoses which included paraplegia and pressure ulcer of the sacral region. A physician's order, dated 11/18/19, documented skin assessments were to be completed every week on Thursday. A review of Resident #7's EHR documented weekly skin assessments 08/29/24 through 10/10/24. On 10/22/24 at 10:10 a.m., the ADON stated skin assessments for Resident #7 that were completed prior to 08/29/24 could not be located.

Based on record review and interview, the facility failed to ensure AIMS assessments were completed for a resident receiving an antipsychotic medication for one (#7) of five sampled residents reviewed for unnecessary medications. The ADON identified two residents received antipsychotic medications. Findings: An undated facility policy titled Monitoring of Anti-Psychotics read in part, .Upon initiation of antipsychotic medication therapy .and every three months thereafter, the Abnormal Involuntary Movement Scale (AIMS) or similar test is administered to the resident. The results, and actions taken in response to the results, are recorded in the resident's medical record . Resident #7 had diagnoses which included unspecified psychosis and anxiety disorder. A physician's order, dated 03/25/24, documented Resident #7 was to receive quetiapine fumarate (an antipsychotic medication) 12.5 mg by mouth every evening. A care plan, dated 09/13/24, documented Resident #7 was receiving an antipsychotic medication and AIMS assessments should be completed according to the facility protocol. A review of Resident #7's EHR indicated an AIMS assessment had been completed on 08/28/24. On 10/22/24 at 11:45 am, the ADON stated no other AIMS assessments could be located for Resident #7.

Based on record review and interview, the facility failed to ensure residents were free from abuse for one (#3) of three residents sampled for abuse. The director of nursing identified 41 residents resided in the facility. An undated facility policy, titled Abuse Prohibition Policy and Procedure , documented in parts . Procedure: Inola Healthcare and Rehab is committed to protecting our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff, and other agencies providing services Resident #3 had diagnoses which included epilepsy, anxiety, and stroke. Resident #1 had diagnoses which included hypertension, encephalopathy, and chronic pain. An incident report, dated 05/01/24, documented that while Resident #3 was trying to sleep, Resident #1 had their cell phone playing loud music and was singing loudly up and down the hallway. When Resident #3 asked Resident #1 to turn the music down and to not sing loudly Resident #1 called Resident #3 fat and a bitch. A care plan for Resident #1, dated 05/18/23, documented the resident demonstrates impulsive behavior. The care plan documented a goal that the resident would be redirected and educated when impulsive behavior occurs and would follow the policy and procedures of the facility. On 05/28/24, at 10:15 a.m., CNA #3 stated Resident #1 calls residents and staff vulgar names. On 05/28/24, at 10:20 a.m., LPN #2 stated Resident #1 yells and curses at residents and staff. The Resident #1 is very confrontational. On 05/28/24, at 11:15 a.m., LPN #1 stated Resident #1 intentionally antagonizes other residents. The police have been called to the facility several times due to the residents behaviors. On 05/28/24, at 2:30 p.m., the social services director stated, when Resident #1 has behavioral outbursts he does it affront of other residents and it causes the residents fear and anxiety. On 05/29/24, at 1:15 p.m., the administrator stated Resident #1 is causing fear and anxiety among other residents to the point that some of them cry. To stop recurrence the medical director has written an order for discharge and they have given the resident a 30 day discharge notice. The Resident #1 is appealing the 30 day discharge and they have a hearing on 06/04/24. The administrator stated they try to redirect the resident when they become belligerent and separate him from other residents. The police have been called to the facility several times due to Resident #1's behavior.

Based on record review and interview, the facility failed to ensure the required number of staff were present when the mechanical lifts were operated for one (#1) of one resident reviewed for mechanical lifts. Findings: Resident #1 had diagnoses which included chronic pain, anxiety, and pulmonary edema A care plan, dated 08/11/23, documented the resident required two person assist with transfers using a Hoyer lift. An Incident Report, dated 03/05/24, read in part, .Staff attempted to put resident in his wheel chair using the Hoyer Lift. While trying to put resident back in .chair resident slid off the chair into the floor. Staff was educated on Hoyer use and the importance of two staff members when using lifts. On 03/11/24 at 2:00 p.m., CNA #4 was asked if they had received an in-service regarding the use of a mechanical lift. They stated, No. On 03/11/24 at 2:05 p.m., CNA #1 and CNA #2 were asked if they had received an in service regarding the use of a mechanical lift. They stated no. On 03/11/24 at 2:10 p.m., CNA #3 and CNA #5 were asked if they had received an in service regarding the use of a mechanical lift. They stated no. On 03/11/24 at 2:15 p.m., CNA #6 was asked if they had received an in service regarding the use of a mechanical lift. They stated no. ON 03/11/24 at 3:15 p.m., the DON stated two people were required to utilize a mechanical lift.

Based on record review and interview, the facility failed to ensure an alleged violation of resident to resident abuse was reported to the state agency for two (#1 and #3) of three sampled residents reviewed for abuse. The administrator identified 41 residents resided in the facility. Findings: An Abuse Prohibition Policy and Procedure, revised 10/30/23, read in parts, .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law .Should a suspected violation or substantiated incident of .abuse (including resident to resident) be reported, the Administrator, or his/her designee, will promptly notify .The State licensing/certification agency responsible for surveying/licensing the facility . 1. Res #1 had diagnoses which included depression. A quarterly resident assessment, dated 11/20/23, documented the resident's cognition was intact. A social service note, dated 02/01/24, documented Res #1 was approached before breakfast time by another resident in an electric wheelchair. It was documented the other resident was hollering and screaming at the nurses' station about Res #1. It was documented Res #1 was coming in from being outside and the other resident started cussing and threatening Res #1. It was documented the other resident tried to run over Res #1 with their electric wheelchair. It was documented the facility administrator was called. On 02/06/24 at 11:27 a.m., Res #1 was interviewed about facility abuse and stated they had a problem with Res #3. They stated Res #3 tried to run them over in their electric wheelchair last week. They stated Res #3 ran into staff instead. They stated Res #3's call light was on the day before and they asked Res #3 if they needed help. They stated Res #3 told them they did not work at the facility and to get out of their room. They stated they were not afraid of Res #3. 2. Res #3 had diagnoses which included depression and pain. A quarterly resident assessment, dated 01/15/24, documented the resident's cognition was intact. On 02/06/24 at 12:44 p.m., Res #3 was interviewed about abuse. They stated Res #1 was a pedophile and they were sick. They stated they had there was an incident where they had their call light on and Res #1 came into their room and they were told to get out. On 02/06/24 at 4:45 p.m., the administrator provided documentation they had on file in their records for an incident involving Res #1 and Res #3. It was documented on 02/01/24 they were called about an incident that was occurring between two residents and employees. It was documented they arrived at the building and started an investigation. It was documented on 01/31/24 Res #1 knocked on Res #3 door because their call light was on. It was documented Res #1 asked Res #3 if they needed help because their call light was on. It was documented Res #3 stated they did not need Res #1's help. It was documented Res #3 yelled at Res #1 telling them they did not work there and to get out of their room. It was documented on 02/01/24 Res #1 was coming in the building from feeding the outside cat. It was documented Res #3 approached Res #1 in their motorized scooter and started yelling and cursing at them. It was documented staff intervened and had Res #1 go behind the nurses desk in an attempt to separate them from Res #3. It was documented Res #3 became agitated at staff and pushed one of them up against the nurses desk with their scooter. It was documented Res #1 called the police to come intervene. There was no documentation the incident was reported to the state agency. On 02/07/24 at 11:30 a.m., the administrator was asked if the incident which occurred on 02/01/24 between Res #1 and Res #3 was reported to the state agency. They stated, No. They stated they did not consider the yelling and cussing to be abusive.

Based on record review and interview, the facility failed to implement their abuse policy to investigate an injury of unknown origin for one (#1) of one sampled resident reviewed for injuries of unknown origin. The administrator reported the census was 47. Findings: An undated policy titled Abuse Prohibition Policy and Procedure, read in part, .all staff are to carefully observe unexplained bruises or abrasions. Upon identification of such a change, the staff member should report the findings immediately to his/her immediate supervisor or the Abuse Coordinator (Administrator). If unable to reach the Abuse Coordinator the Director of Nurses should be notified .Signs of/ Actual Physical Abuse .Fractures, dislocations or sprains of questionable origin .All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law . Resident #1 had diagnoses which included acute respiratory failure and dysphagia. A quarterly assessment, dated 08/07/23, documented the resident was in a persistent vegetative state and was totally dependent on staff for care. A nurse note, dated 09/17/23 at 2:27 p.m., documented on 09/16/23 at 8:00 a.m., the nurse noticed Resident #1's wrist looked swollen and was warm to the touch and that the nurse contacted the physician to get an order for an X-ray. The note further documented the results from the X-ray were returned to the facility on [DATE] around 7:00 a.m. and the results were inconclusive. The physician was notified, and they ordered another X-ray. The note further documented the second X-ray was taken around 1:00 p.m., and the nurse viewed on the monitor that the wrist looked dislocated. The note documented the family and physician were notified, and the resident was sent to the hospital for treatment. An Incident/Accident Report, dated 09/17/23, documented Resident #1's left wrist was possibly dislocated, and the incident was unwitnessed. A nurse note, dated 9/17/23 at 9:00 p.m., documented the hospital called the facility to let them know Resident #1 had a slight dislocation and a hairline fracture of the left wrist and would be returned to the facility. On 10/10/23 at 2:50 p.m., LPN #3 stated on 09/16/23 the resident's wrist was swollen, warm, and looked funny. They stated they thought it might have been dislocated. LPN #3 stated they notified the physician and then contacted the ADON. They reported they were unsure if an investigation took place or why the administrator was not notified until 09/17/23. At 3:30 p.m., the owner, who was functioning as the administrator at the time of the incident, stated that they were notified of the incident on 09/17/23 at 2:40 p.m., and they filed an OSDH form 283 with the Oklahoma State Department of Health within two hours of them being notified. They also stated that the nurse that noticed the injury on 09/16/23 should have notified them so they could have filed the OSDH form 283 at that time. At 3:53 p.m., the DON stated no cognitive residents were interviewed, no staff members were interviewed, and no other residents were assessed related to this incident. They stated no investigation was done because the injury was not acute due to the resident being diagnosed with osteopenia at the hospital on 09/17/23.

Based on record review and interview, the facility failed to ensure care plans were reviewed and revised after a quarterly assessment for three (#14, 25, and #33) of 13 sampled residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 47 residents resided in the facility. Findings: 1. Res #33 admitted to the facility with diagnoses of chronic respiratory failure, attention to tracheostomy, chronic atrial fibrillation, and attention to gastrostomy. Review of the clinical record revealed the care plan for Res #33 was last revised on 04/20/23. A review of the clinical record for Res #33 revealed a quarterly assessment was completed on 08/07/23. 2. Res #14 admitted to the facility with diagnoses of attention to tracheostomy, anoxic brain damage, anxiety disorder, and attention to gastrostomy. Review of the clinical record revealed the care plan for Res #14 was last revised on 02/03/23. A review of the clinical record for Res #14 revealed a quarterly assessment was completed on 05/23/23. 3. Res #25 admitted to the facility with diagnoses of anxiety, generalized edema, congestive heart failure, dyspnea, and hyperlipidemia. Review of the clinical record revealed the care plan for Res #25 was last revised on 12/22/22. Review of the clinical record for Res #25 revealed a quarterly assessment was completed on 06/20/23. On 08/28/23 at 12:14 a.m., MDS Coordinator #1 reported the care plans should have been reviewed/revised with the quarterly assessments.

Based on record review and interview, the facility failed to ensure four (#14, 33, 36, and #46) of 13 sampled residents were turned and repositioned based on professional standards of practice. The Resident Census and Census and Conditions of Residents report, dated 08/20/23, documented 47 residents resided in the facility. Findings: A Repositioning policy, dated October 2010 documented residents who are in bed should be on an every two hour turning program. 1. Res #14 admitted to the facility with diagnoses of anoxic brain damage, attention to tracheostomy, attention to gastrostomy, contracture- unspecified knee, hand, and hip. A quarterly assessment, dated 05/23/23, documented the resident's cognition was severely impaired and required total assistance with all ADL's. An ADL log, dated August 2023, documented 13 missed opportunities to turn and reposition the resident. 2. Res #33 admitted to the facility with diagnoses of chronic respiratory failure, attention to tracheosotomy, attention to gastrostomy, and pain unspecified. A quarterly assessment, dated 08/07/23, documented the resident's cognition was severely impaired and required total assistance with all ADL's. An ADL log, dated August 2023, documented 13 missed opportunities to turn and reposition the resident. 3. Res #36 admitted to the facility with diagnoses of attention to tracheostomy, attention to gastrostomy, unsprcified convulsions, and other muscle spasms. A quarterly assessment, dated 05/15/23, documented the resident's cognition was severely impaired and required total assistance with all ADL's. An ADL log, dated August 2023, documented 12 missed opportunities to turn and reposition the resident. 4. Res #46 admitted to the facility with diagnoses of respiratory failure, attention to tracheostomy, attention to gastrostomy, and cerebral vascular accident. An admission assessment, dated 07/15/23, documented the resident's cognition was severely impaired and required total assistance with all ADL's. An ADL log, dated August 2023, documented 13 missed opportunities to turn and reposition the resident. On 08/28/23 at 2:40 p.m., the ADON was shown the ADL logs and stated the residents should have been turned and repositioned every two hours.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure care was provided by staff who were trained and qualified to provide care to residents who had [DIAGNOSES REDACTED]. Resident #3 had chronic [MEDICAL CONDITION] and required a ventilator to breathe. On [DATE] the resident requested the respiratory nurse change a filter on the ventilator tubing. The resident complained after the filter change that she was not getting any air and the ventilator machine was alarming. The ventilator tubing's and connections were checked and the charge nurse was asked to assist. There was no improvement noted and the resident's oxygen saturation continued to worsen. The nurse then contacted the respiratory consultant for consultation. The resident's oxygen saturation continued to worsen and the ventilator was replaced with a different ventilator machine with no improvement. 911 was called and the resident was bagged to provide respiratory support until the ambulance arrived. There was no documentation of the resident's oxygen saturation levels or vital sign readings during the episode of respiratory distress. The resident was transferred to the hospital due to respiratory distress. Emergency Department notes documented the resident presented to the emergency department with difficulty breathing due [MEDICAL CONDITION]. The examination note documented the resident stated the nurse changed her filter and she couldn't breathe after that. Hospital records documented the resident's Troponin levels were elevated. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator and the DON were informed of the IJ regarding ventilator care and qualified staff and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 5:04 p.m., an acceptable plan of removal was received from the administrator and the DON. The plan of removal documented: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY All nurses will be in serviced immediately by the Respiratory Consultant (name deleted). The Respiratory Consultant (name deleted) will train RN/DON as the specialized Respiratory trainer. IN SERVICE, [DATE], at 5:15 pm, TO INCLUDE AS FOLLOWS: 1. Ventilator unit orientation 2. Ventilator Operations- Trilogy 100 ventilator 3. Documentation for ventilator's 4. Documentation in Treatment Books (RT Cart) 5. Schedule and Duration For Medication Delivery (RT Cart) 6. Tracheotomy Care 7. Inline Breathing Treatments with Ventilator's 8.[MEDICAL CONDITION] Cannula Change 9.[MEDICAL CONDITION] change and/or reinsertion 10. Indications and use of Manual Resuscitation bag 11. Oral Suctioning 12. Oxygen Concentration set up with Ventilator's 13. Oxygen Concentration set up, nasal Cannula, simple O2 mask. 14. Portable Oxygen set up and use 15. Indications of need for oxygen tank change 16. Ventilator Circuit Change with all accessories 17. Delivery of breathing treatments via small volume Nebulizer 18. Respiratory Assessment skills (breath sounds, HR, B/P, RR) 19. Signs and symptoms of Respiratory Distress (Example: facial expression, pale/flush (color), Gasping) 21. Signs and symptoms of Respiratory infection (Example: color, smell, texture) 22. Understands Code status and reaction 23. Sense of Urgency on all alarms sounds 24. Location and information of Vent. Protocol Book 25. Be sure to assess Resident prior to Treatment/reacting Example: look for S/S of distress Alarm Messages Low Peep High Peep Low Pressure High Pressure Disc Sense Return ventilator competencies and demonstrations, by all nurses, with observation and check-off by (name deleted) Respiratory Consultant. Staff were interviewed on [DATE] and ventilator competencies were reviewed. All components to the plan of removal had been completed. The IJ was removed effective [DATE] at 11:05 a.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ care was provided by staff who were trained and qualified to provide care to residents who had [DIAGNOSES REDACTED].#3) of five sampled residents who required ventilator machines for breathing; and ~ assess and monitor the resident's status during an emergency event for one (#3) of one sampled resident who required emergent respiratory support, who was on a ventilator. The facility identified 20 residents who required ventilator machines for breathing. Findings: A facility policy, titled Ventilator Alarm Response and Assessment, documented, .Staff will respond to ventilator alarms immediately and complete an assessment of the situation to determine the cause and resolve the situation .Staff will respond to all ventilator alarms immediately. Licensed nursing and respiratory are responsible to respond to the alarm .Unlicensed staff will report to RT or Nursing immediately when an alarm is noted. Appropriate staff will respond and determine needed action .Staff to assess the resident immediately and determine if the tubing is connected, O2 saturations and vital signs are with in normal limits and if there are any signs distress .Determine which alarm is sounding and address the issue. See below for each alarm and action to take . Pressure Limit Alarm- Suction the resident. High pressure alarms may be caused from the resident coughing or an obstruction from the resident coughing or an obstruction in the airway, such as HME obstruction from secretions or mucus plugs in [MEDICAL CONDITION]. Apnea Alarm- The patient may not be breathing. Assess the situation and use the Ambu bag hooked to an O2 flow meter at 15ml/m to ventilate the patient . Low Minute Volume or Tidal Volume is low- The patient is not breathing enough, respiratory rate is to low and check sedation . Low pressure Alarm- Check for an under-inflated cuff or a leak in the vent circuit. Do not over inflate the cuff. Use minimal leak technique to inflate tracheal cuff . High Respiratory Rate- Alarms when resident respiratory rate is higher than the set alarm. This usually indicates respiratory distress. Suction the resident as needed and bag the resident as needed . Ventilator Settings .Purpose: Educate licensed staff (CRT, RRT, LPN, RN) on the settings of the ventilator. To help staff understand what the settings represent in accordance with proper treatment of [REDACTED]. Ventilator settings: Respiratory Rate (RR) . Tidal Volume (Vt) . Inspiratory Time (I time) . PEEP (Positive End Expiratory) . Pressure Support (PS) . Inspiratory Pressure . Modes of Ventilation: Assist Control (A/C) SIMV (Synchronized Intermittent Mandatory Ventilation) [MEDICAL CONDITION] (Continuous Positive Airway Pressure) Measured Values: RR total .total RR that the resident is breathing set + spontaneous . Vte .exhaled tital volume . VE .symbol for minute volume . I:E ratio .inspiratory: expiratory ratio . PIP .Peak Inspiratory Pressure . MAP .Mean Airway Pressure . Alarms: High Pressure . Low Minute Volume . Low Pressure . **One thing to always remember with ventilator residents is when you are not sure what to do with the machine you should always bag them. When you are ever in doubt bag them and let the vent alarm until someone can come and help . Attention all licensed personnel . ***No one is to change ventilator settings without physicians order . No one is to do ventilator weaning trials without approval of ADM., DON and (name deleted, respiratory consultant) and written orders from Dr . Use of Manual Resuscitation Bag on Residents with Artificial Airways . Indications for use: .Resident is in respiratory distress .If needed during suctioning .[MEDICAL CONDITION] .During CPR .Other situations as indicated by the resident assessment and needs .Ensure that the resuscitation bag is attached to the oxygen source .Set the oxygen for the maximum setting of O2 to be delivered to the resident .Attach the outlet of the resuscitation bag to the resident's airway. If the resident is on the ventilator or a t-tube flow by humidification/oxygen device, these must be removed. The bag then must be attached to the airway .Once the bag is attached to the airway, squeeze bag to deliver manual breath to the resident .Observe the resident (sic) chest rise and fall during the procedure to ensure that adequate ventilation is occurring. Equal, bilateral chest rise should be observed .Compress the bag every five seconds to allow the resident to exhale completely. This will prevent hyperinflation of the lungs. If bagging during CPR utilize current AHA reccomendations (sic) the process should continue until the situation is resolved or emergency services have arrived . Resident #3 was admitted to the facility on [DATE] with chronic [MEDICAL CONDITION] and required a ventilator to breathe. A care plan, dated [DATE], documented, Problem: .I have a [MEDICAL CONDITION]. This places me at increased risk for: Infection, Skin/Stoma breakdown, Respiratory Distress/Insufficiency, Communication Barrier, Aspiration, Ineffective Airway Clearance. Goal: I will remain free from complications R/[MEDICAL CONDITION]& will maintain a patent airway through the next review. Approaches: Administer oxygen per physician's orders [REDACTED].@ 40 degrees or higher at all times. Monitor me for S/S Resp Distress: SOB, Dyspnea, Increase RR, Decrease on Sats, Cyanosis. Report to Physician abnormal findings. Monitor my Respirator settings per Facility Protocol [MEDICAL CONDITION] per Physicians (sic) orders . The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. A quarterly assessment, dated [DATE], documented the resident has a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. The care plan, updated [DATE], documented, .Problem: .I am able to self suction. I also prefer to do my [MEDICAL CONDITION] Goal: Ensure proper technique is used to self suction + [MEDICAL CONDITION]. Approaches: Educate on proper suction technique [MEDICAL CONDITION] . The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. Monthly physician's orders [REDACTED].Vent Settings . AC MODE VT: 500; RR: 14; PEEP 5; O2 ,[DATE]L VIA VENT TO TRACH May titrate to keep SaO2 >88% Respiratory Distress Settings AC MODE RR 16; VT 500; PEEP 5 .Chronic [MEDICAL CONDITION], unspecified whether with [MEDICAL CONDITION] or hypercapnia . Trach care .Daily .[MEDICAL CONDITION] . [MEDICAL CONDITION] & PRN .Daily . Change Outer Cannula Monthly & PRN Patency To be changed by RT Bivonna #7 .[MEDICAL CONDITION] . A physician's progress note, dated [DATE], documented the resident was negative for wheezes, had ventilator support, and was ventilator dependant. The note documented the resident had [DIAGNOSES REDACTED]. A weekly tracking note by the DON, dated [DATE] did not address the resident was on a ventilator or any issues regarding the resident's respiratory status. A nurse's note, dated [DATE] at 3:30 p.m., documented, Res resting c HOB @ 40 (degrees). A/O X 4.[MEDICAL CONDITION] vent in place. (No) resp. distress @ this X. Suctions self. Turns/repositions per her request. (No) c/o pain or discomfort @ this X. C/L in reach. A physician's telephone order, dated [DATE] at 5:30 a.m., documented, Transfer to hosp of choice - (hospital, name deleted) Resp distress. A nurse's note, dated [DATE] at 5:45 a.m., documented, CNA called this nurse to res room + said that res needed a new filter on tubing. Filter was changed @ that time. Res c/o that she wasn't getting any air, vent was alarming. This nurse checked all tubing's + connections to no avail. This nurse asked the other nurse on duty to assist, and we changed out all the tubing. Res O2 sats declining. Contacted RT Consultant who advised us to take all water out of (illegible) and replace it. O2 sats cont to drop, ventilator changed out to no avail. Called 911 and began bagging res. + continued until ambulance arrived. Res transported via ambulance to (hospital, name deleted). Res daughter contacted + will meet them there. There was no documentation found in the clinical record of the resident's oxygen saturation levels or vital sign readings during the episode of respiratory distress. An EMS/ambulance note, documented, .PT on ventilator having breathing problems .At scene: 06:11 (6:11 a.m.) .Shortness of breath/[MEDICAL CONDITION] .Upon EMS arrival, Pt is found semifowlers in bed and very anxious. Nursing staff reports the Pt started to feel like she wasn't getting any air and on examination of the Pt it was determined there was a problem with the trach. Nursing staff called the RT and he stated that it sounded like the cuff blew. However the Pt is unsure of what is wrong but she doesn't believe that cuff blew because she has experience with that. Upon my arrival the Pt was being bagged by the nursing staff and oxygen saturation was 100%. Pt was having thick copious secretions and was having to suction herself often. Pt originally wanted to go to (hospital, name deleted) but then changed her mind and wanted us to take her to (hospital, name deleted) .Leave scene: 06:44 (6:44 a.m.) An emergency department nurse's note, at 7:30 a.m., documented, .ventilator Patient arrived being ventilated by ambu bag through a 7.0 TTS Bivonna Trach. She was placed on a ventilator in the AC mode at 14 bpm w/act. at 19 bpm; VT is set at 430mls w/act. at474mls; Ti is at 0.9 sec.; with 40% fio2 and 5cm peep, she is oxygenating at 100% sao2. The p/p is at 26cm pip and 22cm plateau . A laboratory report, dated [DATE], collected at 7:40 a.m., documented the resident's Troponin I level was 0.089 with a reference range of 0XXX,[DATE].028. The reported documented this result was high. Medline Plus at //medlineplus.gov/ency/article/ 2.htm, documented: .Troponin test A troponin test measures the levels troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged, such as occurs with a [MEDICAL CONDITION]. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood .Normal Results Cardiac troponin levels are normally so low they cannot be detected with most blood tests .What Abnormal Results Mean Even a slight increase in the troponin level will often mean there has been some damage to the heart . The article also documented elevated troponin levels may also be due to some medical conditions or procedures. An emergency department nurse's note, at 8:23 a.m., documented, .Patient presented to ED with difficulty breathing due [MEDICAL CONDITION]. Patient was brought to ED by .EMS. Patient states the nurse changed my filter and I couldn't breath after that. Patient states I feel much better now on the ventilator here . A physician's emergency department note at 9:25 a.m., documented, .History of present illness .history of [MEDICAL CONDITION] secondary to polio presenting via EMS with respiratory distress [MEDICAL CONDITION]. Patient is on home ventilator and woke up overnight with difficulty breathing. She had her filter changed and her breathing became worse. She was then transported by EMS and bagged the whole way and feeling better. There were increased secretions noted that were suctioned. She arrived much improved .Patient is alert .on current home ventilator setting, no cuff leak noted. Pressures normal .critical care consulting for vent management . A laboratory report, dated [DATE], collected at 4:17 a.m., documented the resident's Troponin I level was 0.455. A laboratory report, dated [DATE], collected at 1:28 p.m., documented the resident's Troponin I level was 0.652. A laboratory report, dated [DATE], collected at 10:44 p.m., documented the resident's Troponin I level was 0.531. A laboratory report, dated [DATE], collected at 5:49 a.m., documented the resident's Troponin I level was 0.409. On [DATE] at 1:45 p.m., LPN #1, the respiratory nurse, was asked about the nurse assignments. He stated he worked as a respiratory nurse. He stated he [MEDICAL CONDITION], suctioning as needed, change the cannulas, did three to four hour vent check rounds, checked for respiratory distress, vent settings, checked total volume, inspiratory pressure, checked the tubings, and changed out equipment/tubings as scheduled. He was asked about the filters and filter changes. He stated he changed the filters every day and as needed. He was asked about the training he received to be the respiratory nurse. He stated he had been a ventilator nurse since 2016 and had followed a respiratory therapist for 32 hours at another facility. He was asked if he had any certifications regarding being a respiratory nurse. He stated no. LPN #1 stated they had a respiratory consultant that was on call 24 hours a day, seven days a week but the nurses were assigned to be the respiratory nurse and did the trach/ventilator care for all the residents that had trachs and ventilators. He was asked how long it had been since they changed from having respiratory therapy personnel manage the ventilators to using respiratory nurses. He stated approximately one month. LPN #1 was asked if he had ever had to call the respiratory consultant. He stated, One time, no one in distress, called regarding the pressure support on the new machine (ventilator) so he told me how to set it up. The ventilator competency was reviewed for LPN #1 and documented a completion date of [DATE]. This was the only competency record provided. At 2:06 p.m., the resident's hospital physician was contacted by telephone. The physician stated upon hospitalizaton the resident stated she was fine until they had changed her filter at the facility. The physician stated they (the respiratory nurses) just aren't qualified to take care of these (ventilator dependent) residents. At 2:15 p.m., LPN #3 was asked if she had worked as a respiratory nurse. She stated yes. She was asked what her duties were as the respiratory nurse. She stated she took care of the residents with ventilators and trachs. The ventilator competency was reviewed for LPN #3 and documented a completion date of [DATE]. This was the only competency record provided. At 2:37 p.m., LPN #7, the MDS/care plan coordinator, was asked what had occurred when the resident was transferred out to the hospital with respiratory distress. She stated she was working an extra shift as the respiratory nurse for the first time and around 5:30 a.m., she went to the resident's room and the resident told her that she wanted her filter changed because she felt like she was not getting enough air. She stated she changed the filter and the resident felt like she was getting no air and her oxygen saturation level was dropping. She was asked about the resident's oxygen saturation levels and vital sign readings. She stated there was not any documentation of the readings because she had given her documentation to the EMS personnel. She stated she realized she shouldn't have afterwards. She was asked if she could remember what the readings were. She stated the resident's heart rate and blood pressure readings were rising and dropping. She stated her heart rate reading was from 60 to 140, her blood pressure was up and down from around ,[DATE] to ,[DATE], and her oxygen saturation levels dropped to around 72%. She stated she made the call to begin bagging the resident when her O2 saturation was at 75% but the level had dropped to 72% before they actually began bagging her. She stated she had asked the other nurse to help her and they changed the filter twice and changed the tubing and also tried a different ventilator machine but nothing helped. She stated during this time she did call the respiratory consultant and he told her things to do but the resident continued to decline and they called 911. She stated they continued to bag the resident to ventilate her until emergency services arrived and took over the resident's care. LPN #7 was asked if she had any training before she was assigned to be the respiratory nurse. She stated, I need more training. The ventilator competency was reviewed for LPN #7 and documented a completion date of [DATE]. This was the only competency record provided. At 3:25 p.m., the respiratory consultant and the DON were asked what the respiratory consultant's role was at the facility. He stated he came to the facility on ce a week and was available by telephone 24 hours a day, seven days a week for any respiratory/ventilator issues. He stated when he came to the facility he checked the ventilators, talked to the residents, checked the flowsheets, and talked with families. He was asked if he had any documentation. He stated, No. He was asked how long he had been consulting at the facility. He stated he had been there the last four weeks. The DON stated, We had problems with the RT's and decided to go with respiratory nurses and the RT to consult. The DON was asked for the nursing training/competencies regarding ventilators. The competencies provided were dated 2014 and 2015. A Resident Physician Chart record, from the hospital, dated [DATE] at 9:59 a.m., documented, .Medical Decision Making .EKG without ischemic changes. Troponin elevated, suspect stress reaction from acute dyspnea. Given aspirin here. Patient admitted with critical care consulting for vent management .Clinical Impression: 1. Dyspnea - Improved 2. Elevated troponin . On [DATE] at 1:30 p.m., LPN #7 was asked about the filters and replacing them on the ventilators. She was asked if the filters could only be connected one way. She stated, I think so, I don't know for sure. At 1:55 p.m., LPN #1 was asked about the filters and if they could only be connected one way. He stated, Not 100% sure, can check. He was asked to demonstrate connecting the filter to the tubing. He was observed to attach tubing to a ventilator in the supply room and connect the filter to the tubing. After he attempted to connect it on each end he stated it would only connect one way. On [DATE] at 10:45 a.m., a resident who used a ventilator and wished to remain anonymous, was asked how he/she felt about the change from respiratory therapists to respiratory nurses. He/she stated they were very concerned and felt less safe with the change. He/she stated, I think that's bad. We have a lot of vents here and it just increases the chance something bad could happen. On [DATE] at 2:33 p.m., the care plan coordinator was asked why there were no care plans to address the use of a ventilator and the care to be provided. She stated, I just haven't done that. The care plan coordinator was asked if there should be a care plan to address the use of a ventilator and the individualized care to be provided. She stated, Yes, that would be a good idea. The care plan coordinator was asked if they had care plan meetings to address the individualized care/interventions for the residents. She stated, We have care plan meetings, but they are basic for everyone. The care plan coordinator was asked who attended the care plan meetings. She stated the social service/activity director, the dietary manager, and herself. She was asked if the respiratory nurses attended the care plan meetings. She stated, No. She was asked if the DON attended the care plan meetings. She stated, No. At 3:08 p.m., the DON and the administrator were asked about the trainings/competencies for the respiratory nurses. They stated most of the nurses had been there, had been trained, and felt they knew how to take care of the residents with ventilators. They were asked why the competencies had not been updated for LPN #7 since 2014. They stated they should have trained everyone more thoroughly when they changed from using respiratory therapists to assigning the nurses to be the respiratory nurse. They stated they had taken the ventilator machine the resident had been on when the incident occurred to the hospital to be checked and it was in proper working order with no issues. The DON was asked if the care plans were reviewed. She stated, I usually look at them. The DON was asked why there were no ventilator care plans to address the use of a ventilator and the care to be provided. She stated, I know we address the trachs. The DON was asked if there should be care plans specific to the use of the ventilators. She stated, It should be. I never thought of that. She stated, Yes. It should have everything to do if there is problems and down the line, step by step for the resident. She was asked if she attended the care plan meetings regarding the residents who required the use of ventilators. She stated, No. I don't. By the looks of the care plan, yeah I should.

On [DATE] an Immediate Jeopardy (IJ) situation was determined to exist regarding the facility's failure to ensure staff who provided respiratory care were trained and qualified to provide care to residents who had [DIAGNOSES REDACTED]. Resident #3 had chronic [MEDICAL CONDITION] and required a ventilator to breathe. On [DATE] the resident requested the respiratory nurse change a filter on the ventilator tubing. The resident complained after the filter change that she was not getting any air and the ventilator machine was alarming. The ventilator tubing's and connections were checked and the charge nurse was asked to assist. There was no improvement noted and the resident's oxygen saturation continued to worsen. The nurse then contacted the respiratory consultant for consultation. The resident's oxygen saturation continued to worsen and the ventilator was replaced with a different ventilator machine with no improvement. 911 was called and the resident was bagged to provide respiratory support until the ambulance arrived. There was no documentation of the resident's oxygen saturation levels or vital sign readings during the episode of respiratory distress. The resident was transferred to the hospital due to respiratory distress. Emergency Department notes documented the resident presented to the emergency department with difficulty breathing due [MEDICAL CONDITION]. The examination note documented the resident stated the nurse changed her filter and she couldn't breathe after that. Hospital records documented the resident's Troponin levels were elevated. The Oklahoma State Department of Health (OSDH) was notified and verified the existence of the IJ situation. At 3:20 p.m., the administrator and the DON were informed of the IJ regarding ventilator care and qualified staff and that a plan of removal was required. They were informed this placed the facility in an extended survey. At 5:04 p.m., an acceptable plan of removal was received from the administrator and the DON. The plan of removal documented: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY All nurses will be in serviced immediately by the Respiratory Consultant (name deleted). The Respiratory Consultant (name deleted) will train RN/DON as the specialized Respiratory trainer. IN SERVICE, [DATE], at 5:15 pm, TO INCLUDE AS FOLLOWS: 1. Ventilator unit orientation 2. Ventilator Operations- Trilogy 100 ventilator 3. Documentation for ventilator's 4. Documentation in Treatment Books (RT Cart) 5. Schedule and Duration For Medication Delivery (RT Cart) 6. Tracheotomy Care 7. Inline Breathing Treatments with Ventilator's 8.[MEDICAL CONDITION] Cannula Change 9.[MEDICAL CONDITION] change and/or reinsertion 10. Indications and use of Manual Resuscitation bag 11. Oral Suctioning 12. Oxygen Concentration set up with Ventilator's 13. Oxygen Concentration set up, nasal Cannula, simple O2 mask. 14. Portable Oxygen set up and use 15. Indications of need for oxygen tank change 16. Ventilator Circuit Change with all accessories 17. Delivery of breathing treatments via small volume Nebulizer 18. Respiratory Assessment skills (breath sounds, HR, B/P, RR) 19. Signs and symptoms of Respiratory Distress (Example: facial expression, pale/flush (color), Gasping) 21. Signs and symptoms of Respiratory infection (Example: color, smell, texture) 22. Understands Code status and reaction 23. Sense of Urgency on all alarms sounds 24. Location and information of Vent. Protocol Book 25. Be sure to assess Resident prior to Treatment/reacting Example: look for S/S of distress Alarm Messages Low Peep High Peep Low Pressure High Pressure Disc Sense Return ventilator competencies and demonstrations, by all nurses, with observation and check-off by (name deleted) Respiratory Consultant. Staff were interviewed on [DATE] and ventilator competencies were reviewed. All components to the plan of removal had been completed. The IJ was removed effective [DATE] at 11:05 a.m., when all components of the plan of removal had been completed. The deficient practice remained at actual harm at an isolated level. Based on observation, interview, and record review, it was determined the facility failed to ensure staff who provided respiratory care were trained and qualified to provide care to residents who had [DIAGNOSES REDACTED].#3) of five sampled residents who required ventilator machines for breathing. On [DATE] resident #3 requested the respiratory nurse change a filter on the ventilator tubing. The resident complained after the filter change that she was not getting any air and the ventilator machine was alarming. The ventilator tubing's and connections were checked and the charge nurse was asked to assist. There was no improvement noted and the resident's oxygen saturation continued to worsen. The nurse then contacted the respiratory consultant for consultation. The resident's oxygen saturation continued to worsen and the ventilator was replaced with a different ventilator machine with no improvement. 911 was called and the resident was bagged to provide respiratory support until the ambulance arrived. The resident was transferred to the hospital due to respiratory distress. Emergency Department notes documented the resident presented to the emergency department with difficulty breathing due [MEDICAL CONDITION]. The examination note documented the resident stated the nurse changed her filter and she couldn't breathe after that. Hospital records documented the resident's Troponin levels were elevated. The facility identified 20 residents who required ventilator machines for breathing. Findings: A facility policy, titled Ventilator Alarm Response and Assessment, documented, .Staff will respond to ventilator alarms immediately and complete an assessment of the situation to determine the cause and resolve the situation .Staff will respond to all ventilator alarms immediately. Licensed nursing and respiratory are responsible to respond to the alarm .Unlicensed staff will report to RT or Nursing immediately when an alarm is noted. Appropriate staff will respond and determine needed action .Staff to assess the resident immediately and determine if the tubing is connected, O2 saturations and vital signs are with in normal limits and if there are any signs distress .Determine which alarm is sounding and address the issue. See below for each alarm and action to take . Pressure Limit Alarm- Suction the resident. High pressure alarms may be caused from the resident coughing or an obstruction from the resident coughing or an obstruction in the airway, such as HME obstruction from secretions or mucus plugs in [MEDICAL CONDITION]. Apnea Alarm- The patient may not be breathing. Assess the situation and use the Ambu bag hooked to an O2 flow meter at 15ml/m to ventilate the patient . Low Minute Volume or Tidal Volume is low- The patient is not breathing enough, respiratory rate is to low and check sedation . Low pressure Alarm- Check for an under-inflated cuff or a leak in the vent circuit. Do not over inflate the cuff. Use minimal leak technique to inflate tracheal cuff . High Respiratory Rate- Alarms when resident respiratory rate is higher than the set alarm. This usually indicates respiratory distress. Suction the resident as needed and bag the resident as needed . Ventilator Settings .Purpose: Educate licensed staff (CRT, RRT, LPN, RN) on the settings of the ventilator. To help staff understand what the settings represent in accordance with proper treatment of [REDACTED]. Ventilator settings: Respiratory Rate (RR) . Tidal Volume (Vt) . Inspiratory Time (I time) . PEEP (Positive End Expiratory) . Pressure Support (PS) . Inspiratory Pressure . Modes of Ventilation: Assist Control (A/C) SIMV (Synchronized Intermittent Mandatory Ventilation) [MEDICAL CONDITION] (Continuous Positive Airway Pressure) Measured Values: RR total .total RR that the resident is breathing set + spontaneous . Vte .exhaled tital volume . VE .symbol for minute volume . I:E ratio .inspiratory: expiratory ratio . PIP .Peak Inspiratory Pressure . MAP .Mean Airway Pressure . Alarms: High Pressure . Low Minute Volume . Low Pressure . **One thing to always remember with ventilator residents is when you are not sure what to do with the machine you should always bag them. When you are ever in doubt bag them and let the vent alarm until someone can come and help . Attention all licensed personnel . ***No one is to change ventilator settings without physicians order . No one is to do ventilator weaning trials without approval of ADM., DON and (name deleted, respiratory consultant) and written orders from Dr . Use of Manual Resuscitation Bag on Residents with Artificial Airways . Indications for use: .Resident is in respiratory distress .If needed during suctioning .[MEDICAL CONDITION] .During CPR .Other situations as indicated by the resident assessment and needs .Ensure that the resuscitation bag is attached to the oxygen source .Set the oxygen for the maximum setting of O2 to be delivered to the resident .Attach the outlet of the resuscitation bag to the resident's airway. If the resident is on the ventilator or a t-tube flow by humidification/oxygen device, these must be removed. The bag then must be attached to the airway .Once the bag is attached to the airway, squeeze bag to deliver manual breath to the resident .Observe the resident (sic) chest rise and fall during the procedure to ensure that adequate ventilation is occurring. Equal, bilateral chest rise should be observed .Compress the bag every five seconds to allow the resident to exhale completely. This will prevent hyperinflation of the lungs. If bagging during CPR utilize current AHA reccomendations (sic) the process should continue until the situation is resolved or emergency services have arrived . Resident #3 was admitted to the facility on [DATE] with chronic [MEDICAL CONDITION] and required a ventilator to breathe. A care plan, dated [DATE], documented, Problem: .I have a [MEDICAL CONDITION]. This places me at increased risk for: Infection, Skin/Stoma breakdown, Respiratory Distress/Insufficiency, Communication Barrier, Aspiration, Ineffective Airway Clearance. Goal: I will remain free from complications R/[MEDICAL CONDITION]& will maintain a patent airway through the next review. Approaches: Administer oxygen per physician's orders [REDACTED].@ 40 degrees or higher at all times. Monitor me for S/S Resp Distress: SOB, Dyspnea, Increase RR, Decrease on Sats, Cyanosis. Report to Physician abnormal findings. Monitor my Respirator settings per Facility Protocol [MEDICAL CONDITION] per Physicians (sic) orders . The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. A quarterly assessment, dated [DATE], documented the resident has a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. A quarterly assessment, dated [DATE], documented the resident had a BIMS score of 15. This score indicated the resident was cognitively intact with skills for daily decision making. The assessment documented the resident had a [DIAGNOSES REDACTED]. The care plan, updated [DATE], documented, .Problem: .I am able to self suction. I also prefer to do my [MEDICAL CONDITION] Goal: Ensure proper technique is used to self suction + [MEDICAL CONDITION]. Approaches: Educate on proper suction technique [MEDICAL CONDITION] . The care plan did not address the resident required a ventilator to breathe as a focused area with a goal and interventions or how care was to be provided if the resident had respiratory distress. Monthly physician's orders [REDACTED].Vent Settings . AC MODE VT: 500; RR: 14; PEEP 5; O2 ,[DATE]L VIA VENT TO TRACH May titrate to keep SaO2 >88% Respiratory Distress Settings AC MODE RR 16; VT 500; PEEP 5 .Chronic [MEDICAL CONDITION], unspecified whether with [MEDICAL CONDITION] or hypercapnia . Trach care .Daily .[MEDICAL CONDITION] . [MEDICAL CONDITION] & PRN .Daily . Change Outer Cannula Monthly & PRN Patency To be changed by RT Bivonna #7 .[MEDICAL CONDITION] . A physician's progress note, dated [DATE], documented the resident was negative for wheezes, had ventilator support, and was ventilator dependant. The note documented the resident had [DIAGNOSES REDACTED]. A weekly tracking note by the DON, dated [DATE] did not address the resident was on a ventilator or any issues regarding the resident's respiratory status. A nurse's note, dated [DATE] at 3:30 p.m., documented, Res resting c HOB @ 40 (degrees). A/O X 4.[MEDICAL CONDITION] vent in place. (No) resp. distress @ this X. Suctions self. Turns/repositions per her request. (No) c/o pain or discomfort @ this X. C/L in reach. A physician's telephone order, dated [DATE] at 5:30 a.m., documented, Transfer to hosp of choice - (hospital, name deleted) Resp distress. A nurse's note, dated [DATE] at 5:45 a.m., documented, CNA called this nurse to res room + said that res needed a new filter on tubing. Filter was changed @ that time. Res c/o that she wasn't getting any air, vent was alarming. This nurse checked all tubing's + connections to no avail. This nurse asked the other nurse on duty to assist, and we changed out all the tubing. Res O2 sats declining. Contacted RT Consultant who advised us to take all water out of (illegible) and replace it. O2 sats cont to drop, ventilator changed out to no avail. Called 911 and began bagging res. + continued until ambulance arrived. Res transported via ambulance to (hospital, name deleted). Res daughter contacted + will meet them there. There was no documentation found in the clinical record of the resident's oxygen saturation levels or vital sign readings during the episode of respiratory distress. An EMS/ambulance note, documented, .PT on ventilator having breathing problems .At scene: 06:11 (6:11 a.m.) .Shortness of breath/[MEDICAL CONDITION] .Upon EMS arrival, Pt is found semifowlers in bed and very anxious. Nursing staff reports the Pt started to feel like she wasn't getting any air and on examination of the Pt it was determined there was a problem with the trach. Nursing staff called the RT and he stated that it sounded like the cuff blew. However the Pt is unsure of what is wrong but she doesn't believe that cuff blew because she has experience with that. Upon my arrival the Pt was being bagged by the nursing staff and oxygen saturation was 100%. Pt was having thick copious secretions and was having to suction herself often. Pt originally wanted to go to (hospital, name deleted) but then changed her mind and wanted us to take her to (hospital, name deleted) .Leave scene: 06:44 (6:44 a.m.) An emergency department nurse's note, at 7:30 a.m., documented, .ventilator Patient arrived being ventilated by ambu bag through a 7.0 TTS Bivonna Trach. She was placed on a ventilator in the AC mode at 14 bpm w/act. at 19 bpm; VT is set at 430mls w/act. at474mls; Ti is at 0.9 sec.; with 40% fio2 and 5cm peep, she is oxygenating at 100% sao2. The p/p is at 26cm pip and 22cm plateau . A laboratory report, dated [DATE], collected at 7:40 a.m., documented the resident's Troponin I level was 0.089 with a reference range of 0XXX,[DATE].028. The reported documented this result was high. Medline Plus at //medlineplus.gov/ency/article/ 2.htm, documented: .Troponin test A troponin test measures the levels troponin T or troponin I proteins in the blood. These proteins are released when the heart muscle has been damaged, such as occurs with a [MEDICAL CONDITION]. The more damage there is to the heart, the greater the amount of troponin T and I there will be in the blood .Normal Results Cardiac troponin levels are normally so low they cannot be detected with most blood tests .What Abnormal Results Mean Even a slight increase in the troponin level will often mean there has been some damage to the heart . The article also documented elevated troponin levels may also be due to some medical conditions or procedures. An emergency department nurse's note, at 8:23 a.m., documented, .Patient presented to ED with difficulty breathing due [MEDICAL CONDITION]. Patient was brought to ED by .EMS. Patient states the nurse changed my filter and I couldn't breath after that. Patient states I feel much better now on the ventilator here . A physician's emergency department note at 9:25 a.m., documented, .History of present illness .history of [MEDICAL CONDITION] secondary to polio presenting via EMS with respiratory distress [MEDICAL CONDITION]. Patient is on home ventilator and woke up overnight with difficulty breathing. She had her filter changed and her breathing became worse. She was then transported by EMS and bagged the whole way and feeling better. There were increased secretions noted that were suctioned. She arrived much improved .Patient is alert .on current home ventilator setting, no cuff leak noted. Pressures normal .critical care consulting for vent management . A laboratory report, dated [DATE], collected at 4:17 a.m., documented the resident's Troponin I level was 0.455. A laboratory report, dated [DATE], collected at 1:28 p.m., documented the resident's Troponin I level was 0.652. A laboratory report, dated [DATE], collected at 10:44 p.m., documented the resident's Troponin I level was 0.531. A laboratory report, dated [DATE], collected at 5:49 a.m., documented the resident's Troponin I level was 0.409. On [DATE] at 1:45 p.m., LPN #1, the respiratory nurse, was asked about the nurse assignments. He stated he worked as a respiratory nurse. He stated he [MEDICAL CONDITION], suctioning as needed, change the cannulas, did three to four hour vent check rounds, checked for respiratory distress, vent settings, checked total volume, inspiratory pressure, checked the tubings, and changed out equipment/tubings as scheduled. He was asked about the filters and filter changes. He stated he changed the filters every day and as needed. He was asked about the training he received to be the respiratory nurse. He stated he had been a ventilator nurse since 2016 and had followed a respiratory therapist for 32 hours at another facility. He was asked if he had any certifications regarding being a respiratory nurse. He stated no. LPN #1 stated they had a respiratory consultant that was on call 24 hours a day, seven days a week but the nurses were assigned to be the respiratory nurse and did the trach/ventilator care for all the residents that had trachs and ventilators. He was asked how long it had been since they changed from having respiratory therapy personnel manage the ventilators to using respiratory nurses. He stated approximately one month. LPN #1 was asked if he had ever had to call the respiratory consultant. He stated, One time, no one in distress, called regarding the pressure support on the new machine (ventilator) so he told me how to set it up. The ventilator competency was reviewed for LPN #1 and documented a completion date of [DATE]. This was the only competency record provided. At 2:06 p.m., the resident's hospital physician was contacted by telephone. The physician stated upon hospitalizaton the resident stated she was fine until they had changed her filter at the facility. The physician stated they (the respiratory nurses) just aren't qualified to take care of these (ventilator dependent) residents. At 2:15 p.m., LPN #3 was asked if she had worked as a respiratory nurse. She stated yes. She was asked what her duties were as the respiratory nurse. She stated she took care of the residents with ventilators and trachs. The ventilator competency was reviewed for LPN #3 and documented a completion date of [DATE]. This was the only competency record provided. At 2:37 p.m., LPN #7, the MDS/care plan coordinator, was asked what had occurred when the resident was transferred out to the hospital with respiratory distress. She stated she was working an extra shift as the respiratory nurse for the first time and around 5:30 a.m., she went to the resident's room and the resident told her that she wanted her filter changed because she felt like she was not getting enough air. She stated she changed the filter and the resident felt like she was getting no air and her oxygen saturation level was dropping. She was asked about the resident's oxygen saturation levels and vital sign readings. She stated there was not any documentation of the readings because she had given her documentation to the EMS personnel. She stated she realized she shouldn't have afterwards. She was asked if she could remember what the readings were. She stated the resident's heart rate and blood pressure readings were rising and dropping. She stated her heart rate reading was from 60 to 140, her blood pressure was up and down from around ,[DATE] to ,[DATE], and her oxygen saturation levels dropped to around 72%. She stated she made the call to begin bagging the resident when her O2 saturation was at 75% but the level had dropped to 72% before they actually began bagging her. She stated she had asked the other nurse to help her and they changed the filter twice and changed the tubing and also tried a different ventilator machine but nothing helped. She stated during this time she did call the respiratory consultant and he told her things to do but the resident continued to decline and they called 911. She stated they continued to bag the resident to ventilate her until emergency services arrived and took over the resident's care. LPN #7 was asked if she had any training before she was assigned to be the respiratory nurse. She stated, I need more training. The ventilator competency was reviewed for LPN #7 and documented a completion date of [DATE]. This was the only competency record provided. At 3:25 p.m., the respiratory consultant and the DON were asked what the respiratory consultant's role was at the facility. He stated he came to the facility on ce a week and was available by telephone 24 hours a day, seven days a week for any respiratory/ventilator issues. He stated when he came to the facility he checked the ventilators, talked to the residents, checked the flowsheets, and talked with families. He was asked if he had any documentation. He stated, No. He was asked how long he had been consulting at the facility. He stated he had been there the last four weeks. The DON stated, We had problems with the RT's and decided to go with respiratory nurses and the RT to consult. The DON was asked for the nursing training/competencies regarding ventilators. The competencies provided were dated 2014 and 2015. A Resident Physician Chart record, from the hospital, dated [DATE] at 9:59 a.m., documented, .Medical Decision Making .EKG without ischemic changes. Troponin elevated, suspect stress reaction from acute dyspnea. Given aspirin here. Patient admitted with critical care consulting for vent management .Clinical Impression: 1. Dyspnea - Improved 2. Elevated troponin . On [DATE] at 1:30 p.m., LPN #7 was asked about the filters and replacing them on the ventilators. She was asked if the filters could only be connected one way. She stated, I think so, I don't know for sure. At 1:55 p.m., LPN #1 was asked about the filters and if they could only be connected one way. He stated, Not 100% sure, can check. He was asked to demonstrate connecting the filter to the tubing. He was observed to attach tubing to a ventilator in the supply room and connect the filter to the tubing. After he attempted to connect it on each end he stated it would only connect one way. On [DATE] at 10:45 a.m., a resident who used a ventilator and wished to remain anonymous, was asked how he/she felt about the change from respiratory therapists to respiratory nurses. He/she stated they were very concerned and felt less safe with the change. He/she stated, I think that's bad. We have a lot of vents here and it just increases the chance something bad could happen. On [DATE] at 2:33 p.m., the care plan coordinator was asked why there were no care plans to address the use of a ventilator and the care to be provided. She stated, I just haven't done that. The care plan coordinator was asked if there should be a care plan to address the use of a ventilator and the individualized care to be provided. She stated, Yes, that would be a good idea. The care plan coordinator was asked if they had care plan meetings to address the individualized care/interventions for the residents. She stated, We have care plan meetings, but they are basic for everyone. The care plan coordinator was asked who attended the care plan meetings. She stated the social service/activity director, the dietary manager, and herself. She was asked if the respiratory nurses attended the care plan meetings. She stated, No. She was asked if the DON attended the care plan meetings. She stated, No. At 3:08 p.m., the DON and the administrator were asked about the trainings/competencies for the respiratory nurses. They stated most of the nurses had been there, had been trained, and felt they knew how to take care of the residents with ventilators. They were asked why the competencies had not been updated for LPN #7 since 2014. They stated they should have trained everyone more thoroughly when they changed from using respiratory therapists to assigning the nurses to be the respiratory nurse. They stated they had taken the ventilator machine the resident had been on when the incident occurred to the hospital to be checked and it was in proper working order with no issues. The DON was asked if the care plans were reviewed. She stated, I usually look at them. The DON was asked why there were no ventilator care plans to address the use of a ventilator and the care to be provided. She stated, I know we address the trachs. The DON was asked if there should be care plans specific to the use of the ventilators. She stated, It should be. I never thought of that. She stated, Yes. It should have everything to do if there is problems and down the line, step by step for the resident. She was asked if she attended the care plan meetings regarding the residents who required the use of ventilators. She stated, No. I don't. By the looks of the care plan, yeah I should.

On 08/08/16 an IJ situation was determined to exist regarding the facility's failure to supervise a resident who required staff assistance with smoking. The resident was observed sitting in a motorized wheelchair under the portico in the resident smoking area. The resident had a cigarette hanging out of his mouth. The resident was observed to only have ROM in his fingers. The resident could not lift his arms to remove the cigarette from his mouth to release ashes or to catch the cigarette if it fell from his mouth. There was one other resident observed outside with the resident while he smoked. There was no staff present. On 08/08/16 at 6:45 p.m., the OSDH was notified and verified the existence of the IJ situation. At 6:50 p.m., the administrator was informed of the IJ situation regarding accident hazards. The administrator was informed this placed the facility in an extended survey and a plan of removal was required. At 8:05 p.m., an acceptable plan of removal was received from the administrator. The plan of removal documented: Immediate plan for smokers that need assistance with smoking: Going forward all residents that smoke will have a smoking assessment completed before smoking on the premises. All current residents that smoke will have a new smoking assessment completed to ensure accuracy of previous assessment and current status. Smoking assessments will be done quarterly and when a change in condition occurs. All staff will be immediately inserviced personally for those on-duty and via phone for those that are not one duty. Inservice to include as follows: All assisted smoking residents will be assisted by staff members only. Cigarettes and lighters for assist smokers will be kept in Med Room to ensure safety of the resident. Any special use equipment such as smoking aprons ect will be observed if stated on the smoking assessment. All resident current smoking assessments will be kept at the nurses station for easy access for referance (sic) as needed. Monitoring: DON and/or designee(s) will routinely monitor smoke area to ensure resident safety and continued compliance. End date/date of completion: August 9th, 2016 6:00pm On 08/09/16 at 1:00 p.m., the resident was observed smoking in the resident's smoking area with a staff member present. Staff were interviewed on 08/09/16, 08/10/16, and 08/11/16 in regard to their knowledge of the in-service related to resident's smoking with staff assistance and staff monitored designated smoking times. Staff interviewed exhibited an understanding of residents who required supervision and assistance with smoking. The IJ was removed effective 08/09/16 at 4:40 p.m. when all components of the plan of removal had been completed. The deficiency remained at a pattern level with a potential for more than minimal harm. Based on observation, interview, and record review, it was determined the facility failed to provide supervision with smoking for one (#17) of three sampled residents reviewed for smoking. The administrator identified four residents who required supervision while smoking. Findings: Resident #17 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 05/03/16, documented the resident was cognitively intact; required total assistance with transfers; required extensive assistance with bed mobility, dressing, eating, hygiene, bathing, and toileting; had impairment of both upper and lower extremities; and required ventilation, tracheostomy care, and suctioning. A smoking safety assessment, dated 05/11/16, documented, .A smoking assessment will be completed on all smoking residents every 3 months and when a condition change occurs with the resident. 1. Is the resident able to self extinguish a cigarette? .Yes 2. Does resident appropriately use an ashtray? .Yes 3. Does resident drop ashes on self? .No 4. Does resident attempt to keep smoking paranephelia (sic) in room? .No 5. Has resident sustained [REDACTED].? .No 6. Does resident comply with smoking regulations of facility? .Yes Assessment: 1. Resident has demonstrated ability to safely smoke cigarettes with minimal supervision . A smoking safety assessment, dated 05/13/16, documented, .A smoking assessment will be completed on all smoking residents every 3 months and when a condition change occurs with the resident. 1. Is the resident able to self extinguish a cigarette? .No 2. Does resident appropriately use an ashtray? .No 3. Does resident drop ashes on self? .No 4. Does resident attempt to keep smoking paranephelia (sic) in room? .No 5. Has resident sustained [REDACTED].? .No 6. Does resident comply with smoking regulations of facility? .Yes Assessment: .Resident requires additional interventions (ie. Smoking apron, cigarette holder, staff assist) to ensure safety while smoking . Additional comments Unable to hold cigarette and put to mouth. Requires staff or other resident to assist while smoking . A smoking safety assessment, dated 07/26/16, documented, .A smoking assessment will be completed on all smoking residents every 3 months and when a condition change occurs with the resident. 1. Is the resident able to self extinguish a cigarette? .No 2. Does resident appropriately use an ashtray? .No 3. Does resident drop ashes on self? .No 4. Does resident attempt to keep smoking paranephelia (sic) in room? .No 5. Has resident sustained [REDACTED].? .No 6. Does resident comply with smoking regulations of facility? .Yes Assessment: .Resident exhibits poor safety awareness when smoking & requires close staff monitoring during smoking. Additional comments (Resident name removed) needs assists lighting cig & also putting cig out in ashtray. Goes out to smoke with other Residents & they help him with his cigarettes. If no other residents are smoking at the time he wants to go out he will ask staff to go with him . An annual assessment, dated 08/02/16, documented the resident was cognitively intact; required total assistance with transfers; required extensive assistance with bed mobility, dressing, eating, hygiene, bathing, and toileting; had impairment of both upper and lower extremities; required ventilation, tracheostomy care and suctioning; and was a smoker. A care plan, dated 08/08/16, documented the resident was a smoker. The care plan goal documented, .I will have no incidents related to smoking and will adhere to facility policy with regard to smoking through next review . Approach Educate resident on facility policy & procedure regarding smoking priveleges (sic) Educate resident regarding safe smoking practices Smoking assessment will be completed every three months and with any change of condition Resident to be assisted with smoking by staff or other residents . On 08/08/16 at 5:25 p.m., resident #17 was observed sitting in a motorized wheelchair underneath the portico in the resident smoking area. A cigarette was observed hanging out of the resident's mouth. Resident #22 was standing next to the resident assisting the resident with lighting the cigarette and catching the resident's ashes. There were no other residents or staff present. On 08/08/16 at 5:35 p.m., resident #17 was asked if staff were ever present when he smoked. He said sometimes a CNA was there and sometimes just other residents. On 08/08/16 at 5:50 p.m., CMA #1 was asked if resident #17 could smoke a cigarette without assistance from staff. CMA #1 stated the resident could only use his fingers in his lap. The CMA stated the resident could not hold a cigarette to his mouth. On 08/08/16 at 5:55 p.m., resident #20 was asked if resident #17 could smoke independently. Resident #20 stated the residents had to help resident #17 because he could not take the cigarette from his mouth. Resident #20 stated there were times ashes would fall from resident #17's cigarette onto his clothes and one of the residents would have to go over and brush off the ashes. Resident #20 stated sometimes staff were present and sometimes only residents were there during smoking times. On 08/08/16 at 5:56 p.m., resident #22 was asked how resident #17 smoked. Resident #22 stated he was always with the resident when he smoked. Resident #22 stated he would light resident #17's cigarette and would then catch the ashes from resident #17's cigarette in his hand. On 08/08/16 at 5:58 p.m., resident #21 was asked if resident #17 could smoke independently. Resident #21 stated no the resident needed help to smoke. Resident #21 stated there were times when ashes fell from resident #17's cigarette onto his clothes and another resident had to help brush off the ashes. Resident #21 stated most times there were only other residents present when resident #17 smoked. She stated occasionally staff would also be present. On 08/08/16 at 6:00 p.m., CNA #1 was asked if the resident could smoke independently. She stated someone had to light the resident's cigarette and put it into his mouth. She stated someone would then have to take the cigarette out of the resident's mouth to tap the ashes or extinguish the cigarette. She stated staff or other residents helped the resident with smoking. On 08/08/16 at 6:08 p.m., the MDS/LPN was asked about the resident's smoking assessment which was completed on 05/11/16. She stated the assessment was not accurate because the resident could not bring the cigarette to his mouth. She stated she had put the cigarette into the resident's fingers and had put the ashtray right next to his hand. She stated that is why another assessment was completed on 05/13/16. On 08/08/16 at 6:10 p.m., MDS/LPN was asked if resident #17 could smoke independently. She stated no someone had to light the cigarette and put it into the resident's mouth and then remove the cigarette to tap the ashes off. She stated if you put the cigarette in the resident's fingers he could hold it in his fingers but could not bring the cigarette up to or from his mouth. The MDS/LPN was asked if the resident was supervised when he smoked. She stated sometimes staff were with him and sometimes he was just with other residents who helped him. On 08/09/16 at 7:35 a.m., the social services director was asked if resident #17 could smoke independently. She stated resident #17 was not safe to smoke independently.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ a resident who received nutrition through a gastrostomy tube received sufficient nutrition to prevent severe weight loss; ~a physician ordered [MEDICATION NAME] lab test used to monitor nutritional status was obtained; and ~ the physician was notified of severe weight loss for one (#13) of nine sampled residents who received enteral nutrition through a gastrostomy tube. The facility census and condition report identified 24 residents who resided in the facility and received enteral nutrition through a gastrostomy tube. Findings: Resident #13 had [DIAGNOSES REDACTED]. A care plan, dated 11/13/15, documented: I have a PEG tube and receive all my hydration/nutrition via PEG tube I will be free from significant weight loss, dehydration, or other complications R/T PEG tube . Dietician consult per facility protocol . Obtain weights per orders/facility protocol . A PAR tracking form entry, dated 04/05/16, documented the resident's weight was 123.6. The weight variance report documented the resident weighed 123.6 pounds on 04/07/16. A dietary progress note, dated 04/20/16, documented, Wt: 123.6 .Recommend [MEDICATION NAME] lab to better assess nutrition status . A dietary recommendation request form, dated 04/20/16, documented the dietician recommended a [MEDICATION NAME] lab test for the resident. The request form documented the physician had signed the recommendation approving the lab test be obtained. A quarterly assessment, dated 05/16/16, documented the resident had no discernable consciousness and was in a persistent vegetative state. The assessment documented the resident required total assistance with all ADL's, was NPO, and received enteral nutrition per continuous infusion. The assessment documented the resident had experienced no weight loss. A dietary progress note, dated 05/17/16, documented, .Previous RD rec accepted for [MEDICATION NAME] lab but no results available at this time. Will monitor for [MEDICATION NAME] lab . A Weight Variance Report, dated 06/01/16, documented the resident weighed 124.5 pounds. A Weight Variance Report, dated 07/07/16, documented the resident weighed 114.5 pounds. This was a severe weight loss of 8% in one month. A dietary progress note, dated 07/08/16, documented, . no new nutrition related labs available . A Weight Variance Report, dated 07/18/16, documented the resident weighed 101.4 pounds. This represented a severe weight loss of 23.1 pounds or 18.5% in one month and 22.2 pounds or 17.9% in three months. The clinical record contained no documentation to indicate the physician had been notified of the resident's severe weight loss. There was no documentation that the [MEDICATION NAME] laboratory test had been obtained. On 08/11/16 at 9:00 a.m., the CDM was asked if the RD or physician had been notified of the resident's significant weight loss. The CDM stated she had given the RD a weight variance report for the resident during her visit on 07/27/16 but no recommendations had been forwarded to the physician. The CDM was asked who was responsible for monitoring weight loss for residents who received enteral feedings. She stated she received the weights for all residents and the RD would be notified of variances. The CDM stated if any residents experienced significant weight loss the DON, MDS/LPN, and the remaining members of the multidisciplinary team were notified and the results would be discussed during weekly team meetings. The weekly team meeting notes were reviewed. The notes contained no documentation to show the physician or RD had been notified of the resident's weight loss. On 08/11/16 at 9:15 a.m., LPN #2 was asked why the pre-[MEDICATION NAME] lab test which had been ordered on [DATE] had not been obtained. He stated he was unsure and the missed order must have had been a communication breakdown. He stated the physician's orders [REDACTED]. On 08/11/16 at 10:45 a.m., the RD was contacted by phone. She was asked if she had been notified of the resident's weight loss. The RD stated when she visited the facility on 07/08/16 there were no current weights available for this resident. She stated the only recommendations for this resident since her 04/20/16 visit were for a [MEDICATION NAME] lab to be obtained. On 08/11/16 at 11:30 a.m., the DON was asked why the resident's physician ordered [MEDICATION NAME] lab had not been obtained. She stated it must have been overlooked. The DON was asked how they ensured a resident who received tube feedings and had experienced weight loss were monitored. She stated if a resident had experienced a significant weight change the physician would be notified. The DON stated the CDM had the trending weights and variances and was responsible for contacting the RD. The DON was asked who was responsible for ensuring a resident who had experienced weight loss had interventions in place to prevent further weight loss. She stated all staff were responsible for ongoing monitoring of the residents weights and notifying the physician regarding resident weight loss. The DON stated resident #13's weight loss had been discussed during weekly team meetings. She was asked why the physician had not been notified of the resident's weight loss. She stated it must have been overlooked.

Based on observation, interview, and record review, it was determined the facility failed to ensure: ~ a resident received sufficient nutrition to prevent severe weight loss; ~a physician ordered [MEDICATION NAME] lab test used to monitor nutritional status was obtained; and ~ the physician was notified of severe weight loss for one (#13) of one sampled residents with severe weight loss. The resident experienced a severe weight loss of 23.1 pounds or 18.5% in one month and 22.2 pounds or 17.9% in three months. The MDS LPN identified three residents who resided in the facility and had experiened a significant weight loss. Findings: Resident #13 had [DIAGNOSES REDACTED]. A care plan, dated 11/13/15, documented: I have a PEG tube and receive all my hydration/nutrition via PEG tube I will be free from significant weight loss, dehydration, or other complications R/T PEG tube . Dietician consult per facility protocol . Obtain weights per orders/facility protocol . A PAR tracking form entry, dated 04/05/16, documented the resident's weight was 123.6. The weight variance report documented the resident weighed 123.6 pounds on 04/07/16. A dietary progress note, dated 04/20/16, documented, Wt: 123.6 .Recommend [MEDICATION NAME] lab to better assess nutrition status . A dietary recommendation request form, dated 04/20/16, documented the dietician recommended a [MEDICATION NAME] lab test for the resident. The request form documented the physician had signed the recommendation approving the lab test be obtained. A quarterly assessment, dated 05/16/16, documented the resident had no discernable consciousness and was in a persistent vegetative state. The assessment documented the resident required total assistance with all ADL's, was NPO, and received enteral nutrition per continuous infusion. The assessment documented the resident had experienced no weight loss. A dietary progress note, dated 05/17/16, documented, .Previous RD rec accepted for [MEDICATION NAME] lab but no results available at this time. Will monitor for [MEDICATION NAME] lab . A Weight Variance Report, dated 06/01/16, documented the resident weighed 124.5 pounds. A Weight Variance Report, dated 07/07/16, documented the resident weighed 114.5 pounds. This was a severe weight loss of 8% in one month. A dietary progress note, dated 07/08/16, documented, . no new nutrition related labs available . A Weight Variance Report, dated 07/18/16, documented the resident weighed 101.4 pounds. This represented a severe weight loss of 23.1 pounds or 18.5% in one month and 22.2 pounds or 17.9% in three months. The clinical record contained no documentation to indicate the physician had been notified of the resident's severe weight loss. There was no documentation that the [MEDICATION NAME] laboratory test had been obtained. On 08/11/16 at 9:00 a.m., the CDM was asked if the RD or physician had been notified of the resident's significant weight loss. The CDM stated she had given the RD a weight variance report for the resident during her visit on 07/27/16 but no recommendations had been forwarded to the physician. The CDM was asked who was responsible for monitoring weight loss for residents who received enteral feedings. She stated she received the weights for all residents and the RD would be notified of variances. The CDM stated if any residents experienced significant weight loss the DON, MDS/LPN, and the remaining members of the multidisciplinary team were notified and the results would be discussed during weekly team meetings. The weekly team meeting notes were reviewed. The notes contained no documentation to show the physician or RD had been notified of the resident's weight loss. On 08/11/16 at 9:15 a.m., LPN #2 was asked why the pre-[MEDICATION NAME] lab test which had been ordered on [DATE] had not been obtained. He stated he was unsure and the missed order must have had been a communication breakdown. He stated the physician's orders [REDACTED]. On 08/11/16 at 10:45 a.m., the RD was contacted by phone. She was asked if she had been notified of the resident's weight loss. The RD stated when she visited the facility on 07/08/16 there were no current weights available for this resident. She stated the only recommendations for this resident since her 04/20/16 visit were for a [MEDICATION NAME] lab to be obtained. On 08/11/16 at 11:30 a.m., the DON was asked why the resident's physician ordered [MEDICATION NAME] lab had not been obtained. She stated it must have been overlooked. The DON was asked how they ensured a resident who received tube feedings and had experienced weight loss were monitored. She stated if a resident had experienced a significant weight change the physician would be notified. The DON stated the CDM had the trending weights and variances and was responsible for contacting the RD. The DON was asked who was responsible for ensuring a resident who had experienced weight loss had interventions in place to prevent further weight loss. She stated all staff were responsible for ongoing monitoring of the residents weights and notifying the physician regarding resident weight loss. The DON stated resident #13's weight loss had been discussed during weekly team meetings. She was asked why the physician had not been notified of the resident's weight loss. She stated it must have been overlooked.

On 03-27-14 at 8:50 a.m., an Immediate Jeopardy (IJ) situation was determined to exist due to the facility's failure to ensure care and services were provided for ventilator dependent residents. The facility failed to monitor a ventilator dependent resident's respiratory status, failed to ensure only licensed personnel managed a resident's ventilator, failed to ensure a resident's facility ventilator alarm system was plugged in and functioning properly, and failed to ensure there was sufficient nursing staff to monitor a ventilator dependent resident's respiratory status. The Oklahoma State Department of Health was notified and verified the Immediate Jeopardy situation. At 10:10 a.m., the administrator and the assistant director of nursing (ADON) was notified of the IJ situation. On 03-27-14 at 2:50 p.m., the administrator stated all staff who were on duty had been in-serviced. On 03-27-14 at 3:15 p.m., an acceptable plan of removal was presented to the survey team. The Plan of Removal documented: "...1. (Respiratory therapist name deleted), has in-serviced every staff member on the clock for the day shift on the ventilators & who can plug the ventilators and external alarms attached to the ventilators, he is in-servicing the 3-11 staff as they come in. The two nurses from 11-7 are being in-serviced at 4 pm today. (Name deleted), RN will in-service the C.N.A's (certified nurse assistant) & the CMA (certified medication aide) on the 11-7 shift prior to them going to the floor tonight. The policy on the ventilators has been provided and has been updated to address who can turn off an alarm of any type connected to the ventilators. 2. (Agency name deleted) will be providing a licensed nurse for the 11-7 shifts for 3/30th, 4/5, 4/6, 4/12, 4/13, 4/19, 4/20. The LPN (licensed practical nurse) from (assisted living center name deleted) will provide the coverage for 3/27, 3/31, 4/1, 4/2, 4/7, 4/8, 4/11, 4/17, 4/18. We have an LPN that can start full time by 4/23/2014..." The IJ was removed on 03-27-14 at 3:22 p.m. when all components of the plan had been completed. The deficient practice remained at a level of no actual harm with potential for more than minimal harm at a pattern. Based on observation, interview, and record review, it was determined the facility failed to ensure care and services were provided for ventilator dependent residents for 2 (#1 and #3) of two sampled residents who were ventilator dependent. The facility failed to: a. monitor the respiratory status for resident #1 and resident #3. b. ensure only licensed nursing staff managed ventilators for resident #1 and resident #3. c. ensure the facility ventilator alarm system was plugged in and functioning properly for resident #1 and resident #3. The ADON identified five residents in the facility who were ventilator dependent. Findings: A facility ventilator alarm response and assessment policy, dated 07-12-12 and updated on 03-27-14, documented, "...Policy: Staff will respond to ventilator alarms immediately and complete an assessment of the situation to determine the causes and resolve the situation. Purpose: To provide education to staff regarding action to taking (sic) when a ventilator alarms. Procedure:...Staff will respond to all ventilator alarms immediately. Licensed nursing and respiratory are responsible to respond to the alarm...Unlicensed staff will report to RT (respiratory therapist) or Nursing immediately when an alarm is noted...Appropriate staff will respond and determine needed action...Staff to assess the resident immediately and determine if the tubing is connected, O2 (oxygen) saturations and vital signs are with in normal limits and if there are any signs of distress...Determine which alarm is sounding and address the issue. See below for each alarm and action to take...Pressure Limit Alarm-Suction the resident. High pressure alarms may be caused from the resident coughing or an obstruction in the airway, such as HME (heat and exchange moisturizer) obstruction from secretions or mucus plugs in the trach...Apnea Alarm-The patient may not be breathing. Assess the situation and use the Ambu bag hooked to an O2 flow meter at 15 ml/m (milliliters per minute) to ventilate the patient...Low Minute Volume or Tidal Volume is low-The patient is not breathing enough, respiratory rate is to low and check sedation...Low pressure Alarm-Check for an under-inflated cuff or a leak in the vent circuit. Do not over inflate the cuff. Use minimal leak technique to inflate tracheal cuff...High Respiratory Rate-Alarms when resident respiratory rate is higher than the set alarm. This usually indicates respiratory distress. Suction the resident as needed and bag the resident as needed...Only licensed nursing staff can touch the ventilator. Only licensed nursing staff can turn a ventilator alarm off. Only a licensed nursing staff can unplug the ventilator or external alarm to the vent..." Resident #1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. An assessment dated [DATE], documented the resident was alert, was totally dependent on staff for all activities of daily living, had an indwelling urinary catheter, received nutrition through a [DEVICE], and required ventilator assisted breathing. An admission/start up order sheet, dated 03-10-14, documented, resident #1 required ventilator assisted breathing at a rate of 16 breaths per minute. The resident required a gastrostomy tube feeding. The ordered tube feeding to be administered was Fibersource at a rate of 60 milliliters and hour. On 03-27-14 at 5:43 a.m., resident #1 was observed in bed with the head of the bed elevated. The resident's eyes were observed to be closed. The resident was being assisted to breathe by a ventilator. The ventilator respiratory rate was set at 16 breaths per minute. The resident was receiving Fibersource 60 milliliters per hour through a gastrostomy tube. The resident's eyes were closed. While the surveyor was in the room licensed practical nurse (LPN) #2 came in the room and plugged something into the wall near the resident's ventilator. She immediately left the room. LPN #2 was observed to go directly across the hall to resident #3's room. LPN #2 was observed to plug something into the wall near resident #3's ventilator. LPN #2 was asked what she had plugged in. LPN #2 stated she had plugged in the facility ventilator alarm and light in resident #1's and resident #3's rooms. LPN #2 was asked why the alarms had not been plugged in. LPN #2 stated, "The certified nurse aides (CNAs) unplugged the alarm to turn the resident. These residents are very sensitive and even their head turning sets off the alarm. They must have just forgotten to plug it back in." On 03-27-14 at 6:20 a.m., CNA #3 was asked what she was allowed to do with the facility ventilators. CNA #3 stated, "I can only push the silent reset button on the ventilator and then I tell the nurse what the ventilator message was." CNA #3 was asked if she ever unplugged the facility ventilator alarm and light. She stated no. CNA #3 was asked if she ever unplugged the facility ventilator alarm and light to provide care to a resident. She stated no. CNA #3 was asked if she was aware resident #1's and resident #3's facility ventilator alarm and light had been unplugged. She stated no. On 03-27-14 at 6:25 a.m., CNA #2 was asked what she was allowed to do with the facility ventilators. CNA #2 stated this was her first night to work in the facility. She stated she had not touched anything on a resident's ventilator. CNA #2 was asked if she had observed another CNA disable the ventilator alarm. She stated she had not observed any CNA disable a resident's ventilator alarm. On 03-27-14 at 7:00 a.m., LPN #3 was asked about resident #1's and resident #3's facility ventilator alarm and light. LPN #3 stated the resident's facility ventilator alarm and light were unplugged when she arrived to work at 11:00 p.m. the previous night. LPN #3 was asked why the resident's ventilator alarm and light had been unplugged. LPN #3 stated the nurse told her the facility ventilator alarm and light had been unplugged because every time the resident coughed it would set off the alarm. She stated she could still hear the ventilator alarm just not the facility alarm system with the light. LPN #3 was asked if she was off the ventilator hall would she be able to hear just the ventilator alarm. LPN #3 stated she might not hear the ventilator alarm if the facility ventilator alarm and light had been unplugged. LPN #3 was asked if she checked the resident's ventilator alarms when she came on shift to ensure the alarms were all activated. LPN #3 stated she did not look at every resident's ventilator alarm to ensure they were activated because she could hear the alarms. On 03-27-14 at 7:30 a.m., LPN #2 was asked how she would know the facility ventilator alarm and light had been unplugged for resident #1 and resident #3. She stated, "I knew they were off because I could hear the vent alarm but did not see the light." She stated she would sometimes tell the CNAs to unplug the facility vent alarm and light during resident care and then have them plug it back in when they were finished. On 03-27-14 at 7:55 a.m., the respiratory therapist (RT) was asked about the ventilator dependent resident's facility ventilator alarm and light. The RT stated if the resident's facility ventilator alarm and light was unplugged it would not sound at the nurses' station. On 03-27-14 at 8:00 a.m., the assistant director of nursing (ADON) was asked if the facility had a policy regarding ventilator alarms. The ADON stated both the ventilator alarm and the facility ventilator alarm and light should be plugged in at all times. The ADON was asked what happened if the facility ventilator alarm was unplugged. She stated the facility ventilator alarm and light would not sound in the hall or at the nurses' station. On 03-27-14 at 8:50 a.m., LPN #2 was asked if she had ever worked at night when there was only one nurse in the building. LPN #2 stated when she arrived to work the previous night at 3:00 a.m., there was only one LPN on duty and she had been alone since 11:00 p.m. LPN #2 was asked if she was ever called away from the vent unit when working alone at night. She stated yes she was occasionally called away but she would make sure there was an aide on the vent hall while she was away taking care of another resident. On 03-27-14 at 9:20 a.m., the administrator was asked about staffing during the 11 p.m. to 7 a.m. shift. She stated she had been actively trying to hire an LPN for the night shift. She stated there had been only one nurse on duty for either part of or all of the 11 p.m. to 7 a.m. shift 14 days during March. On 03-27-14 at 4:15 p.m., resident #1 was observed lying in bed with the head of the bed elevated. The resident's eyes were observed to be open. The resident was being assisted to breathe by a ventilator. The facility ventilator alarm and light were observed to be plugged in. The resident was receiving Fibersource 60 milliliters per hour through a gastrostomy tube. Resident #1 was asked if staff treated her with dignity and respect. Resident #1 shook her head yes. Resident #1 was asked if she received incontinent care as needed. Resident #1 shook her head yes. 2. Resident #3 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A quarterly assessment, dated 12-30-13, documented the resident was comatose, required total assistance with activities of daily living, was always incontinent of bowel, had an indwelling urinary catheter, had a gastrostomy feeding tube, and was on a ventilator. On 03-27-14 at 5:44 a.m., during a tour of the unit LPN #2 was observed going into resident #3's room and plugging in the facility ventilator alarm and light. Resident #3 was observed lying in bed with the head of the bed up. She had a [MEDICAL CONDITION] connected to a ventilator. Resident #3 did not exhibit any signs or symptoms of distress. On 03-27-14 at 9:25 a.m., resident #3 was observed lying in bed with her eyes closed. The head of the bed was up. She was on a ventilator and the ventilator was plugged in. Resident #3 did not exhibit any signs or symptoms of distress.

Based on observation, interview, and record review, it was determined the facility failed to ensure that residents maintained their highest levels of well-being for 1 (#5) of 2 sampled residents who were reviewed for a change in condition. The facility failed to assess, monitor, and intervene when a resident had a change of condition. The resident experienced an extended hospital stay for acute [MEDICAL CONDITIONS], urinary tract infection, and dementia with [MEDICAL CONDITION] secondary to urinary tract infection, and dehydration. The director of nursing (DON) identified one resident who had a change of condition in the last three months. This had the potential to affect 57 residents identified by the DON who resided in the facility. Findings: A facility policy titled, "Change in a Resident's Condition or Status," documented, "...Our facility shall promptly notify the resident, his or her Attending Physician...of changes in the resident's medical/mental condition and/or status...The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been...A significant change in the resident's physical/emotional/mental condition...The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status..." Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's care plan, dated 05-03-12 and last updated 01-17-13, documented the resident's care preferences and her basic care requirements. The resident's care plan did not address the resident's change of condition or the urinary tract infections. A quarterly assessment, dated 01-17-13, documented the resident was severely cognitively impaired, required extensive assistance with activities of daily living, and was incontinent of bowel and bladder. A physician's telephone order, dated 03-11-13, documented, "...UA (urinalysis) with C&S (culture and sensitivity) if indicated..." A review of resident #5's clinical record contained no documentation or clinical assessment for the change in condition which required a UA to be done. A preliminary laboratory report, dated 03-13-13, documented a urinalysis with "...HEAVY GRAM POSITIVE GROWTH..." and "...1+ blood/hemoglobin... 2+ leukocyte esterase... 4+ bacteria...100-150 WBC's (white blood cells)..." A physician's telephone order, dated 03-14-13, documented, "UA with C&S." A review of resident #5's clinical record contained no documentation or clinical assessment for the change in condition which required a UA to be done. A review of laboratory results revealed no C&S in the resident's clinical record. A laboratory result for a UA, dated 03-21-13, documented, "...large UA blood...large UA LK (leukocyte) esterase... 4+ bacteria...WBC TNTC (too numerous to count)..." A physician's telephone order, dated 03-22-13, documented "...Bactrim 400/800 mg (milligrams) 1 tab (tablet) po (by mouth) Bid (twice daily) x (times) 1 week for UTI (urinary tract infection)." A nurses' note, dated 03-30-13 on the 7 a.m. to 3 p.m. shift, documented, "...Res (resident) had temp of 101 (degrees) this a.m. Tylenol 325mg ii/ii (2) po (by mouth) admin (administered) @ 10:10 (a.m.). At 11:00 (a.m.) temp is 98.8. No adverse reaction to completed ATB (antibiotic) noted. At 1330 (1:30 p.m.), res still afebrile. Seems very tired and weak. Will mon. (monitor)..." A nurse's note, dated 03-30-13 on the 3 p.m. to 11 p.m. shift, documented, "...T (temp) 98.8, resident remains confused, no s/s (sign and symptoms) of discomfort with urination, daughter worried about lingering UTI..." A review of resident #5's clinical record did not contain documentation that the physician had been notified of the change in the resident's mental status or condition. A nurse's note, dated 04-01-13 on the 3 p.m. to 11 p.m. shift, documented, "...Daughter insisted on repeat UA, & (and) wants her to see Dr. (name deleted) d/t (due to) cont. (continued) confusion, ntd (noted) peri area swollen & red, urine cloudy, UA obtained, T 99..." A laboratory preliminary report for a UA obtained on 04-02-13 documented, "...trace blood/hemoglobin... 1+ leukocyte esterase... 4+ bacteria...2-4 WBC's..." A handwritten notation documented by the resident's physician on the bottom of the report documented "...C/S..." and was noted by the nursing staff. A physician's progress note, dated 04-02-13, documented, "...UTI, Confusion, Dementia...Plan...Bactrim DS (double strength) Bid x 7d (days)..." A review of resident #5's clinical record did not show documentation of the C&S result to the UA that was obtained on 04-02-13 as the physician had ordered. A physician's telephone order, dated 04-03-13, documented, "[MEDICATION NAME] 200mg i (1) po x 1 for yeast infection..." There was no documentation in the resident's clinical record from 04-03-13 to 04-08-13 which documented the condition of the resident's yeast infection. A nurses' note, dated 04-08-13, documented, "...V/S (vital signs) (a blood pressure) 81/45 (pulse rate) 65 (temperature) 98.0 (respirations) 18, Resident had a change in mental status & choking on meds, food & liquids, Sent to hospital for eval & TX (treatment) per physicians order..." A physician's telephone order, dated 04-08-13, documented, "...To hospital for eval & Tx (treatment) may transport via ambulance..." The resident's hospital admission laboratory results, dated 04-08-13, documented the resident's white blood count was too-numerous-to-count (normal range is 0-4), bacteria was 3 plus (normal is 0), blood urea nitrogen was 90 (normal range is 5-20), creatinine was 3.35 (normal range is 0.57 to 1.11), and potassium was 5.9 (normal range is 3.5 to 5.0). An annual assessment, dated 04-17-13, documented the resident was moderately impaired cognitively, required extensive assistance with activities of daily living, and was occasionally incontinent of bowel and bladder. A hospital discharge summary, dated 04-18-13, documented the resident's discharge [DIAGNOSES REDACTED]...1. acute [MEDICAL CONDITION] 2. [MEDICAL CONDITION]. 3. Urinary tract infection...resolving..." The discharge summary further documented other [DIAGNOSES REDACTED]...1. Dementia with [MEDICAL CONDITION] secondary to urinary tract infection and dehydration 2. [MEDICAL CONDITION] 3. possible pneumonia 4. Hypertension 5. Depression 6. Diabetes mellitus, type 2 and 7. Possible [MEDICAL CONDITION]." The resident was readmitted to the facility on [DATE] after a ten day stay at the hospital. On 05-06-13 at 2:30 p.m., resident #5 was observed sitting in her recliner with her feet elevated. She was clean and well-groomed. She was alert and oriented. Her speech was garbled with a few words understandable when questioned. Resident #5's daughter was at the bedside. On 05-07-13 at 10:21 a.m., LPN #1 was asked if there was documentation as to why the physician ordered UAs and antibiotic treatments. She stated, "There is nothing documented." LPN #1 was asked about her assessment the day resident #5 was sent to the hospital. She stated, "It was her daughter that wanted her sent to the hospital and I agreed. She was choking on her food, not acknowledging to even swallow." On 05-07-13 at 10:35 a.m., LPN #1 obtained the C&S reports from the UAs that were done on 03-11-13, 03-22-13, and 04-12-13. She was asked if the doctor had received the culture reports. She stated, "No, I guess not since I just printed them out today." She was asked how the physician received copies of the culture and sensitivity reports. She stated the facility received them from the lab and then sent the results to the physician. LPN #1 was further asked if nursing staff was assessing hydration status of the resident while she was on antibiotics. She stated, "We chart push fluids." When questioned what that meant, she stated, "We tell the aides to give residents extra fluids." The LPN was asked if there was any documentation for the extra fluids, how much, and if the resident was taking them. She stated, "No." On 05-07-13 at 10:50 a.m., the resident's attending physician was asked how he determined which antibiotic was appropriate. He stated, "I was given the UA results and based upon the fact she showed 4+ bacteria and trace blood, I decided to treat with an antibiotic. I did ask for the C&S results." The physician was asked about his progress note, dated 04-02-13, of a UTI and increased confusion. He stated, "Yes, per the note I felt that since she was off Bactrim for 2 days but was still showing signs of confusion, my assumption was that it wasn't enough (antibiotics)." He further stated that he had not seen the C&S reports. The physician was then asked if he felt like the staff should have been monitoring hydration on her especially since she was on an antibiotic. He stated, "Yes, they certainly should have done that." On 05-07-13 at 5:45 p.m., The director of nursing (DON) and assistant director of nursing (ADON) were asked how often they offered fluids to residents. They stated, "At meals, medication pass, snacks, and activities. We encourage the aides to offer the residents' fluids when going into their room for cares." The DON and ADON were asked if fluid intakes of residents were documented in the clinical record. The DON stated, "No, except for those residents on I&O (intake and output) for tube feedings."